Please read, and forward to your state regulatory agency

[DianaCox]

I might have contributed to this ... it is very damaging, regressive and what Anthem BC does in CA, often gets promulgated to other BC franchisee, and other insurance companies.
~~~~~~~~~~
http://blog.dssurgery.com/2015/01/weight-loss-surgery-coverage-changes.html

Weight loss Surgery Coverage Changes

Weight loss surgical procedures have been proven to be the only viable option for sustained weight loss when compared to all other modalities, including diet, exercise, behaviors modifications, appetite suppressant, and other less scientific approaches.

Different weight loss procedures have had varying degree of success as measured with resolution of the co-morbidities and long term weight loss.

In December of 2014, Blue Cross of California notified the providers of a number of changes in their coverage will be taking place.

One such specific modification in policy involves primary and revision weight loss surgery.


These policy changes have significant practical implications for those seeking surgical treatment for morbid obesity and associated co-morbidities.

First of all, they create a road block for those patients who are not able to provide documentation for the "...6 continuous months, in the 2 years prior to surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance." It also places the responsibility on the surgeon by requiring that compliance with these requiremens are ".... fully appraised and documented by the physician requesting authorization for surgery."

The practical implication of this is much longer wait between the first office visit with a surgeon and the ability to obtain authorization unless a patient comes in with 6 months’ worth of documentation. The impropriety of such medically unsubstantiated requirements, including the unacceptable and harmful effect of delay or denial on access to medically necessary treatment, was addressed by the ASMBS in the March 2011 position statement on Preoperative Supervised Weight Loss Requirements (http://asmbs.org/resources/preoperative-supervised-weight-loss-requirements). These new requirements are inconsistent with the ASMBS Position Statement and should be vigorously opposed.

The second and in my opinion more restrictive and significant change is for revision procedures. It indicates that any patients in need of a medically necessary revision surgery, must meet the criteria for initial weight loss surgery. This can dramatically limit access to revision surgery for those who are having complications, e.g., of the Adjustable Gastric banding procedures (because they are unable to eat, having constant nausea and vomiting, abdominal pain etc.) or gastric bypass (dumping syndrome, solid intolerance, etc.) but who do not meet the weight criteria or have documentation for 6 months of “ … participation in a non -surgical weight loss ..." since they were not trying to lose weight.

This should also concern those who have or perform the duodenal switch as a staged procedure, where the sleeve is done as the first step, to be followed by the completion of duodenal switch operation at a later time. Although I am generally against a staged approach to the duodenal switch operation, this policy change introduces unnecessary and even insurmountable hurdles for those patients for whom this approach is deemed medically necessary.

For all those who are not in California, please note that a lot of policies do start here and propagate to the rest of the country. I would propose that everyone take time to contact their state health insurance providers regulatory agency and voice their opposition to the proposed changes.

The state regulatory agencies are located here. (http://www.dsfacts.com/image-files-new/agencies-by-state.pdf)

 

[swimbikerun]

DianaCox thank you for this. Most horrible. Then again, I have dealt with Anthem BCBS of Va. and it doesn't surprise me. The mentality there some days ... I work for the govt and at least in our areas we are NOT any where near this bad.

I might have contributed to this ... it is very damaging, regressive and what Anthem BC does in CA, often gets promulgated to other BC franchisee, and other insurance companies.
~~~~~~~~~~
http://blog.dssurgery.com/2015/01/weight-loss-surgery-coverage-changes.html

Weight loss Surgery Coverage Changes

Weight loss surgical procedures have been proven to be the only viable option for sustained weight loss when compared to all other modalities, including diet, exercise, behaviors modifications, appetite suppressant, and other less scientific approaches.

Different weight loss procedures have had varying degree of success as measured with resolution of the co-morbidities and long term weight loss.

In December of 2014, Blue Cross of California notified the providers of a number of changes in their coverage will be taking place.

One such specific modification in policy involves primary and revision weight loss surgery.


These policy changes have significant practical implications for those seeking surgical treatment for morbid obesity and associated co-morbidities.

First of all, they create a road block for those patients who are not able to provide documentation for the "...6 continuous months, in the 2 years prior to surgery, to enable both behavioral changes and adequate assessment of anticipated postoperative dietary maintenance." It also places the responsibility on the surgeon by requiring that compliance with these requiremens are ".... fully appraised and documented by the physician requesting authorization for surgery."

The practical implication of this is much longer wait between the first office visit with a surgeon and the ability to obtain authorization unless a patient comes in with 6 months’ worth of documentation. The impropriety of such medically unsubstantiated requirements, including the unacceptable and harmful effect of delay or denial on access to medically necessary treatment, was addressed by the ASMBS in the March 2011 position statement on Preoperative Supervised Weight Loss Requirements (http://asmbs.org/resources/preoperative-supervised-weight-loss-requirements). These new requirements are inconsistent with the ASMBS Position Statement and should be vigorously opposed.

The second and in my opinion more restrictive and significant change is for revision procedures. It indicates that any patients in need of a medically necessary revision surgery, must meet the criteria for initial weight loss surgery. This can dramatically limit access to revision surgery for those who are having complications, e.g., of the Adjustable Gastric banding procedures (because they are unable to eat, having constant nausea and vomiting, abdominal pain etc.) or gastric bypass (dumping syndrome, solid intolerance, etc.) but who do not meet the weight criteria or have documentation for 6 months of “ … participation in a non -surgical weight loss ..." since they were not trying to lose weight.

This should also concern those who have or perform the duodenal switch as a staged procedure, where the sleeve is done as the first step, to be followed by the completion of duodenal switch operation at a later time. Although I am generally against a staged approach to the duodenal switch operation, this policy change introduces unnecessary and even insurmountable hurdles for those patients for whom this approach is deemed medically necessary.

For all those who are not in California, please note that a lot of policies do start here and propagate to the rest of the country. I would propose that everyone take time to contact their state health insurance providers regulatory agency and voice their opposition to the proposed changes.

The state regulatory agencies are located here. (http://www.dsfacts.com/image-files-new/agencies-by-state.pdf)

 

[Sue]

ahhh such a refreshing post, it is nice when an insurance company acts in the best interest of the patients and not for themselves-oh shit, wait I was dreaming.
Well unfortunate this fucking bull shit was already in practice at least last year if not before in many Anthem BCBS. I fucking love the 6 month supervised diet, continuous, what the fuck does that even mean anyway, is the surgeon going to live with me for 6 months, I don't like my surgeon that much!!! That is so absurd, I mean come on. I don't think they can defend their position; they just want to deny you, assholes they are. And of course an oldie but a goodie is all initial medically necessary criteria must be met for repeat procedures. What fucking jackass thought this one up?? Really you hold MO to a unique standard, since you don't require that of any other disease state. Ohhh your diabetic medication is not working, sorry wait till your glucose is back to 300 again then try another medication, but not before. Ohhh your CABG didn't work, well have another heart attack then we will bypass another one, but hey not before that. Yes exactly that is fucking insane, and I still don't think they can defend their position on something stupid like that, just because they say so, but I will have my turn to test that belief. Can't wait till it's my turn, I won't give up.

 

[Larra]

As usual, these new requirements have nothing to do with medical necessity or the welfare of the policy holders. They are just another way to deny care and save money for the company. It's a business, and nothing more.
I think another point against this is that for many revision patients, they surgeon is far from home, esp for RNY to DS or VBG to DS patients. How on earth is a surgeon half way across the country supposed to provided 6 months of continuous monitoring of this dietary effort? Is the patient supposed to make monthly plane rides across the country? The realities of revision surgery are such that for many, this requirement will be impossible to fulfill.

 

[JackieOnLine]

As usual, these new requirements have nothing to do with medical necessity or the welfare of the policy holders. They are just another way to deny care and save money for the company. It's a business, and nothing more.

a business that provides NOTHING, IMO. all it exists for is to make money by denying care. the opposite of what we need in health "care" !!!

 

[DianaCox]

I have now forwarded the link and discussed this with my at the DMHC. I got the following response (after s/he did some additional research):

I spoke with our licensing division regarding the review of plan medical policies. The Knox-Keene Health Care Service Plan Act of 1975 (Act) does not require plans to file their medical policies with the Department as part of the Licensing process. However, the Act has strong protections around the development and application of medical policies. Plans must file their policies and procedures around medical policy development and utilization management. The Department has a number of mechanisms in place to oversee and take action where a plan has violated the Act.

Any consumer that has a plan regulated by the DMHC may file a complaint with their health plan and then file a complaint/IMR request with the DMHC if they are unsatisfied with the plans grievance resolution.

If the Department finds that a particular plan is acting at variance the issue may be reviewed by our survey, auditing and/or enforcement division.​

To which I responded:

Excellent. I will advise Dr. Keshishian that if he has a patient who has these new policies applied, he should tell them they can file a complaint and then appeal in order to get the policies reviewed. (And, that he can refer them to me [and Larra] to help file the complaint and appeal.)​

So, now we need an Anthem patient (of any CA surgeon - doesn't have to be a DSer) who is going to have to comply with this new rule, who is willing to let us help them file a complaint while they are complying - they could be “paying it forward” even before they have surgery.

 

[Barbara W]

I am new to the group and stumbled across this thread trying to find anything in writing to fight Anthem BCBS of CA. I am in NC, but my husband's insurance is based out of CA. My doctor verified benefits 1/7/15. I finished all my requirments and doctor filed for pre-authorization 2/12/15. They were sent a denial a week later, due to now requiring a 6 month supervised diet!! Told doctor policy changed 1/13/15. I have my husband's employer helping us look into it, since the verificatuon 1/7 did not require diet. I am looking for in writing that this policy was revised 1/13/15 and is effective 3/15/15. If I can get that proof in writing, I will have more to fight with. Do you all know where I can get this information that you posted above on some corrispondence with the BCBS logo???? My doctors office will contact me tomorrow to tell me how they plan to fight it. What else can I do?

 

[DianaCox]

I cannot guess which policy controls, and whether the CA Dept of Managed Health Care has jurisdiction over your appeals. You need to find these things out.

Interestingly, I found this: https://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/surgery_for_morbid_obesity.pdf
At the very end, in the discussion of the revisions to the policy:

7/15/14 References added. Specialty Matched Consultant Advisory Panel review 5/14/2014. Coverage criteria for long limb Roux-en-Y and biliopancreatic bypass with duodenal switch added to When Covered section. Under Revision Bariatric Surgery in When Covered section, additional criteria added at C. Under When Not Covered section, removed biliopancreatic bypass and Roux-en-Y for failed Nissen Fundoplasty from list. Added "Laparoscopic gastric plication (laparoscopic greater curvature plication [LGCP]) with or without gastric banding” to When Not Covered section. Clarification added to nutritional evaluation guidelines. Requirement that patient be an active participant in non-surgical weight reduction program for at least 6 months prior to surgery removed. (sk)

2/10/15 Information on laparascopic gastric plication added to Description section. Reference added. No change to Policy statement. (sk)

I'm not sure how things work in CA, where BC is Anthem, and seems to be more separate from BS of CA (I SHOULD know better, since my plan is Carefirst BCBS of VA, but I'm on a Blue Card and live in CA). I found this, for Anthem: http://www.anthem.com/medicalpolicies/policies/mp_pw_a053317.htm

The evidence in the peer-reviewed medical literature to support the use of gastric bypass with a Roux-en-Y procedure (RYGB) up to 150 cm and/or vertical banded gastroplasty (VBG) for the indication of clinically severe obesity suggests that these procedures are beneficial for this indication in a selected group of individuals. The Swedish Obese Subjects (SOS) intervention trial reported a large reduction in diabetes over a 5.5 year mean follow-up for the surgery group. Peri-operative mortality varies by procedure, surgeon, and center, and occurs at a rate of approximately 1 in 200 procedures. In order to minimize potential morbidity and mortality, individuals who undergo such treatment should meet specific criteria prior to undergoing the procedure. The preoperative workup should include documentation by the treating physician of active participation in a formal weight reduction program for at least 6 months duration, in the 2 years prior to surgery, that includes serial documentation of all weights, as well as dietary and exercise regimens. Conservative weight loss efforts should be fully appraised by the physician requesting surgical authorization, so that preoperative assessment of the individual's capability for appropriate behavioral changes can be determined. A 6 month preoperative assessment of anticipated postoperative dietary compliance is a prudent indicator of anticipated postoperative successful weight loss which could be maintained over time.

In the Document History:
Document History
StatusDateAction
Revised11/13/2014Medical Policy & Technology Assessment Committee (MPTAC) review. The medically necessary criteria were revised to indicate that active participation in a formal preoperative weight loss program must be documented for at least 6 continuous months in the 2 years prior to surgery. The criteria for repeat procedures were clarified to indicate that ALL initial medically necessary criteria must again be met. The Rationale and References were updated.
But at the top, it says
Current Effective Date: 01/13/2015
Status:Revised Last Review Date: 11/13/2014

As for BS of CA: https://www.blueshieldca.com/provid...wnload/public/bscpolicy/Bariatric_Surgery.pdf

• Documentation of active participation in a non-surgical weight reduction program supervised by a registered dietician, healthcare provider (e.g., physician, nurse practitioner), or an organized weight reduction program (e.g., Weight Watchers™, Jenny Craig™), for at least six consecutive months occurring within the last 18 months prior to the request for bariatric surgery
• Monthly documentation of all of the following weight reduction program components:
• Weight
• Dietary regimen, which may include medical nutrition therapy (e.g., MediFast™ and OptiFast™) or a recognized commercial diet-based weight loss program (e.g., Weight Watchers™, Jenny Craig™, etc)
• Physical exercise unless medically contraindicated
• Behavior modification or behavioral health interventions

The appendix to this document indicates that the effective date was "Effective Date: 6/28/2013"

So that doesn't help you. You need to see if you can get the NC BCBS criteria to apply to you.

 

[Barbara W]

Ok, I will check NC. The way my husband explained it, is all bills get filed to NC BCBS. Then they pay the bills and then Anthem pays NC. But I guess Anthem has final say in pre-authorizations.

I am just frustrated that this can all change even after I started the process. I had no issue with doing a 6 month diet, if that was originally on their requirement list.

Thanks for the information!

 

[DianaCox]

Ask the employer for a copy of your Evidence of Coverage document. Is your plan self-funded or fully funded? To whom do you appeal an adverse decision on preauthorization? This is important!

 

[Barbara W]

Ok Thanks! My husband is the one who handles this stuff, so will pass on that information to him to get the answers.

I am going to assume the doctors office knows how to handle this, but want to be prepared for me to get involved.