Question:
Can someone give me any information about BC/BS?

I have already started the process with my old insurance company Cigna PPo. I just recently found out that the company I retired from is switching to BC/BS PPO as of Jan 1st 2003. What are the requirements from this new company? I have so many co-morbidities but what about stuff like diets. I am so upset about this change that I've kinda just put the brakes on the whole thing. I've already had my initial consult with my surgeon and was hopeing to have surgery, like he wanted before the 1st of the year but that's definetly not going to happen now. I also have Medicare as my secondary insurer. any thoughts would be appreciated. Thanks, Claire    — gramof3 (posted on December 22, 2002)

December 22, 2002
Claire - Unfortunately this is impossible to answer because not all BC/BS policies are created equal. I consider myself a BC/BS expert related to my policy, as I have been to war and won with them a number of times. Many things factor in like is it a standard BC/BS policy or has your employer modified the policy and added or excluded some things.<p>I'm going to give you my gut reaction based on the little information you have provided. Because the plan you are going to is a PPO there is a good chance it is a covered procedure as long as your employer did not exclude it. The best place to start is to look in the exclusions section of your benefits booklet. There usually is a statement in there about no coverage for treatment of weight loss etc. etc. But then the exclusion goes onto say except in the case of morbid obesity and disease etiology (co-morbidities). This is the open door you want to look for. This says under the right circumstances it will be covered. Assuming your policy has that exclusion, then the next thing to do is contact customer service and find out what they require for approval review.<p>They will require a psych eval, letter of medical necessity either from the surgeon or your PCP, listing of what weight loss attempts have been made and their success, and most likely will be looking for at least 1 physician/diet center supervised attempt at weight loss, although they did not say it quite that way to me. They also will require an after surgery treatment/weight loss/exercise plan that the surgeon can provide. They want to know that you will be followed and there are expectations etc. It is important that they know that you have tried a few times and also what other medical conditions are severely affected by the weight. They require the obvious things of morbid obesity - 40 BMI and 100lbs over.<p>My letter just went in at the end of last week. I know it is a covered procedure and that I qualify but am not 100% sure if the documentation of weight loss attempts will be an issue. I have some physician supervised attempts like from Redux and Xenical and also using Wellbutrin to curb my appetite the last 7-8 months, but I'm not sure how they will feel about the Wellbutrin. The Xenical I only did for 2 months as I could not tolerate it. The Redux qualifies but that is 5-6 years back already and if you go back to 94/95 I have 13 months of documented 200 lb weight loss and then obviously gained it back over the past years. I'm hoping it will go smoothly.<p>You definitely need to pursue it. Even if it is clearly excluded, if you have the pieces of info to support your case file an appeal. You have nothing to lose. If they cover treatment of morbid obesity, worst case scenario should be that they want you to try a physician supervised weight loss program first, which they will pay for because it relates to morbid obesity. I got them to pay for Redux medication and all associated tests and physician visits, so I know it can be done. Good Luck!
   — zoedogcbr

December 22, 2002
I have Blue Cross PPO and I had no problems getting them to pay for my surgery. I have a lot of info on my profile if you want to check it out. Basically I got approval for surgery in three days without any co-morbities. My policy did have an exclusion for WLS etc. but Morbid Obesity is considered and exception to the exclusion so everything was covered. Just make sure on all of the tests that you have done as a pre op, the Dr. codes them as 278.01 which is morbid obesity and then the insurance will pay for everything. Good Luck. Wendi Open RNY 9/19 down 70lbs
   — lovemonterey

December 22, 2002
This is one of those questions that no one can really answer for you. Chris says she needed a psych eval. I have Anthem BC/BS of Colorado PPO and did not need one. I did not have a hard time getting approved, but I did need 5 years of documented weight loss attempts. What you will need to have/document depends on your policy. Unless someone else works for the same employer you do, in the same state, you can't really get a definitive answer. Get a copy of the employee handbook as soon as you can and read it to find out if they cover it, and if so, what criteria they have before they will approve.
   — garw

December 22, 2002
I think the psych eval may even be a state mandated thing in some states. Both my surgeon and BC/BS said I must have it. The surgeon knew I had a history of depression, although it is his standard policy, but BC/BS would not have known so it was obviously SOP here for them. WI has a lot of different laws than some states, so it might have been required. I know others have indicated that certain states require it. Personally I think it is a good thing as there are typically so many emotional things that factor into our long history of being obese and it's best to be sure you are able to deal with it and understand the seriousness of the surgery.
   — zoedogcbr

December 23, 2002
Claire, I'm inclined to agree with Chris' post...in each state, BCBC whether PPO, POS or otherwise operates differently. I too, consider myself an expert to MY particular plan. You didn't mention whether it was a federal plan or anything. Under normal circumstances, your surgery of chioice is more than likely covered unless there are specific exclusions in your policy by your employer. It might be a good idea to just take the time and read through your benefits book. IF you meet the criteria, over 100% of your ideal body weight, BMI (Body Mass Index >35 and an abundance of co-morbidities, chances are you would be covered. A psych evaluation was not required in my case-why? I don't know. You will also need to complete a diet history-documented attempts at trying to lose weight but MD supervised and on your own (with proof). Another good idea is to make sure that the surgeon you decide to go to has a good aftercare program. My surgeon provided all of that including a psychologist if necessary for additional *coping* adjustments. Again, take time to go over your benefits package with your Human Resource Department, ASK QUESTIONS of whomever is in charge there, AND call the BCBS plan where you live. Be SPECIFIC in asking your questions and be persistent. Don't give up~~since Medicare is secondary and another option, call them and request information if you are not sure. Be proactive and persistent~you can't go wrong! Hope this helps some!~~~
   — yourdivaness

December 23, 2002
Hadiyah makes a good point about calling the insurance company's customer service line and asking whether they cover it or not. No matter what they tell you, ask them to send you a copy of the place in the policy to support what they say. The person I talked to said they didn't cover it, but I asked for them to send that to me in writing. Then I saw that it didn't cover 'weight loss' attempts, but did cover WLS if you met their criteria. Never take what they tell you on the phone as gospel. Get it in writing!
   — garw