Question:
empire BC/BS requirements, What are they? how can I find out what I need to get in

order? They already todl me there isnt an exclusion , I need a med ness,which I have,they also need a pre-cert... but what else do I need? I cant seem to find any info on the website, Please Help me I have been trying to get this surgery for 6yrs and this is my first big break and I want all my ducks in a row Kim {fl}    — witchywoman (posted on August 1, 2006)

August 1, 2006
Well basically I would contact the insurance company just to find out what they look for. Most companies require a 6 month min controled diet, and some companies are now asking for a year long diet. This diet must be controled by a PCP. Good Luck
   — Steve Cohen

August 1, 2006
I had my surgery June 29th and I am a bc/bs client. I needed the following things to be approved: 1. Medical diagnosis from the perspective surgeon 2. A letter from my pcp stating that the surgery is medically necessary, treatment process for more than 1 year (all of my weight loss trials), and that your pcp approves of the surgery 3. A letter from a nutritionist 4. A letter evaluating your mental state from a therapist Hopes this information helps. It took 3 months for my approval.
   — nycysiti

August 1, 2006
Kim, Usually whatever surgeon you use, their insurance person will already know what it is you need and will tell you. My surgeon gave me a list of all the things I need. The only thing the surgeon asked from my PCP was my medical history and the weight loss records she has been keeping on me since December. Find you a surgeon that is on Empire BC/BS and make an appointment to see them. Some bariatric clinics require potential patients to come to a seminar prior to making an appointment with the surgeon. They have a person there that will go over with you everything you will need to gain approval. I have Cigna and I performed a search on their website using the keyword bariatric and they have a position paper and in that paper it tells of requirements have to be met in order to have the surgery.
   — the7thdean

August 1, 2006
When I had my surgery in June of 2005, I had empire BC/BS. They required 6 months of documented Dr Approved Diet, Documented weight gain/loss over 6 months (via Dr), Medically approved statement from Primary Dr, Psychological evaluation (was 2 part). Once all that was done and all the other tests that was required, I was approved within 1 week of my surgeon submitting my paperwork to the insurance company. If you have any other questions, feel free to email me privately
   — mzb2u

August 3, 2006
Thank you so much for your answers to this question.
   — witchywoman

August 4, 2006
Look for clinical guidelines for bariatric surgery on your insurance website, or call them and ask them to send you a copy of their clinical guidelines for the surgery. that should tell you all you need to know.
   — Novashannon

August 8, 2006
I have Empire BCBS I can tell you that their website is out-dated and does not include all of their criteria. You must have a 6 month medically supervised diet (no break in diet) if you skip a month you start over, a referral from your PCP saying it is medically necesassary and the following Medical Appropriateness Criteria for Pre-authorization or Claim Review In order to consider payment of surgery (CPT 43842, 43846 and 43847) for obesity the patient: 1. must be at least 100 pounds over ideal weight as defined by the Metropolitan Life Tables or has a body mass index exceeding 40 kilograms per meter squared (see tables that follow); OR 2. must have a body mass index over 35 kilograms per meter squared and a clinically serious comorbidity such as obstructive sleep apnea, hypoventilation, diabetes, hypertension, osteoarthritis, coronary artery disease, severe hyperlipidemia or musculoskeletal dysfunction, AND must meet all of the criteria below has failed to lose weight significantly or has gained weight despite compliance with a multidisciplinary medically supervised non-surgical weight-loss program including prescription obesity medication, a very low calorie diet, supervised exercise, behavior modification and support; AND has no specifically correctable cause for obesity (secondary obesity)
   — SassySteph