I have no clue what my insurance companies policy is.

[Soonerjoseph]

I recently got BCBS of Oklahoma through the ACA. I am so confused on what my policy is concerning bariatric surgery.

First, I've researched all over the interwebs and found Oklahoma chose to include bariatric surgery as an Essential Health Benefit. And according to what I've read (and I could be wrong about this, it's all so damn confusing), that means all plans on the ACA exchange in oklahoma have to include bariatric surgery.

The problem is, my insurance seems to exclude it unless medically necessary. Here's the exact wording:

"For treatment of obesity, including morbid obesity, regardless of the patients history or diagnosis, including but not limited to the following: weight reduction or dietary control programs; surgical procedures;..."

Anyone know what's going on?

 

[southernlady]

Tagging @DianaCox for you.

 

[Soonerjoseph]

I have a wonderful PCP that will do just about anything I ask of him. I'm thinking I should go to him, get him to say why bariatric surgery is medically necessary for me (without including reasons concerning weight, right?), and then... should I have him refer me to a surgeon? And then use the surgeon to file for bariatric surgery with my insurance (this will be for either a sleeve or gastric bypass for now), wait patiently for the denial...and then contact Lindstrom Obesity Advocates. Because I know this is going to be a fight that I can't win without help, and I was willing to pay to go to mexico anyway.

Does this sound about right as far as the process I should take? At what point should I fight for the DS specifically? At the end, I'm thinking of going to Bernita M. Berntsen in Topeka, KS for the DS, who is vetted on the good DS boards on the internet. Should I go to her to get approval right after my PCP? Or should I go to another Dr. here in Oklahoma, get approval for the sleeve/bypass, then fight for the DS after I (hopefully) get approved for bariatric surgery in general?

I would call Lindstrom up right now but I don't know if they can help me until I get a denial from my insurance.

 

[Soonerjoseph]

Here's the only information I've been able to find concerning BCBS of oklahoma and bariatric surgery: http://www.medicalpolicy.hcsc.net/medicalpolicy/activePolicyPage?lid=i4sdmiq5&corpEntCd=OK1


Now this has to be about the dumbest fuckin thing I've ever seen.

"Gastric bypass using a Roux-en-Y anastomosis, adjustable gastric banding, sleeve gastrectomy or biliopancreatic bypass (Scopinaro procedure) with duodenal switch are considered experimental, investigational and/or unproven for the treatment of any condition other than morbid obesity, including but not limited to metabolic syndrome, gastroesophageal reflux disease and sleep apnea."

What kind of shit is BCBS trying to pull? They're making it impossible to get this surgery with this double-talk.

 

[DianaCox]

Medically necessary, AFAIK, means meets the NIH guidelines.

• BMI > 40
• BMI >35-40 and at least one serious comorbidity

That's it.

 

[chevtow]

It says its experimental for any condition OTHER than morbid obesity. So if you are morbidly obese it should be good. But if you have reflux and youre not obese and want the DS to solve it, you're shit outta luck

 

[DianaCox]

http://www.medicalpolicy.hcsc.net/medicalpolicy/activePolicyPage?lid=i4sdmiq5&corpEntCd=OK1

• Biliopancreatic bypass (Scopinaro procedure) WITH duodenal switch (open or laparoscopic) may be considered medically necessary as a surgical treatment option for morbidly obese patients with BMI of 50 kg/m² or greater who meet the other eligibility criteria for surgery.

If your BMI is less than 50, you could probably still fight it. However, the policy does expressly state:

The following procedures are considered not medically necessary as a treatment of morbid obesity:​

• • Vertical banded gastroplasty is no longer a standard of care.
  • Biliopancreatic bypass with duodenal switch is considered not medically necessary as a treatment for patients with a BMI less than 50kg/m².

"Gastric bypass using a Roux-en-Y anastomosis, adjustable gastric banding, sleeve gastrectomy or biliopancreatic bypass (Scopinaro procedure) with duodenal switch are considered experimental, investigational and/or unproven for the treatment of any condition other than morbid obesity, including but not limited to metabolic syndrome, gastroesophageal reflux disease and sleep apnea."

You missed the key words there.

 

[Soonerjoseph]

Here's my policy: https://www.healthcare.gov/see-plan...c09533d3be4c325f2c5ad50b3ad189824933&start=20

Bariatric surgery near the bottom

And this one, which says not for treatment of obesity:
http://www.bcbsok.com/pdf/sbc/87571OK0310004-01.pdf

And then this, which says the opposite:
http://health.usnews.com/health-ins...-solution-4-a-multi-state-plan-87571OK0310004

Anyway, my deductible and out-of-pocket is $500 which is why I'm choosing to fight for the surgery this way. It's not the 6k+ that these policies are stating.

 

[Soonerjoseph]

I have an awesome hospital administrator from a JCI accredited hospital that's going to talk to BCBS and see what's going on. She says she deals with them all the time...don't know if she can help but it certainly can't hurt.

 

[DianaCox]

Obesity: ICD9 278.00 - not covered
Morbid Obesity: ICD9 278.01 - covered

 

[Soonerjoseph]

Obesity: ICD9 278.00 - not covered
Morbid Obesity: ICD9 278.01 - covered

Where are you seeing that? Is that just something you know because you've been through this and can look up what the policy states exactly? Does this mean it's carte blanche to have bariatric surgery as long as I'm Morbidly Obese?

 

[DianaCox]

It is something I know. You can't get bariatric surgery for OBESITY - but MORBID OBESITY is a different ICD9 code.

On YOUR policy (or at least the one I think is yours: http://www.medicalpolicy.hcsc.net/medicalpolicy/activePolicyPage?lid=i4sdmiq5&corpEntCd=OK1):

1. Diagnosis of morbid obesity, defined as a:

• Body mass index (BMI) equal to or greater than 40 kg/meter² (* see guidelines below for BMI calculation); OR
• BMI equal to or greater than 35kg/meters² with at least one (1) of the following clinically significant obesity-related diseases or complications that are not controlled by best practice medical management:
  • Hypertension, OR
  • Dyslipidemia, OR
  • Diabetes mellitus, OR
  • Coronary heart disease, OR
  • Sleep apnea, OR
  • Osteoarthritis; AND

2. Documentation from the requesting surgical program that:

• Growth is completed (generally, growth is considered completed by 18 years of age); AND
• Documentation from the surgeon attesting that the patient has been educated in and understands the post-operative regimen, which should include ALL of the following components:
  • Nutrition program, which may include a very low calorie diet or a recognized commercial diet-based weight loss program; AND
  • Behavior modification or behavioral health interventions; AND
  • Counseling and instruction on exercise and increased physical activity; AND
  • Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health; AND

• Patient has completed an evaluation by a masters level or higher behavioral healthcare provider acting within the scope of their licensure under applicable state law, within the 12 months preceding the request for surgery. This evaluation should document:
  • The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations, AND
  • The absence of any psychological comorbidity that could contribute to weight mismanagement or a diagnosed eating disorder, AND
  • The patient’s willingness to comply with preoperative and postoperative treatment plans.

 

[Soonerjoseph]

Actually my PCP is a PA that works for a surgeon that did a surgery on me years ago. I bet I could get this whole thing going fast if he's brought along. My policy doesn't actually start until June 1st though so I still have a month to plan on what to do.

 

[robs477]

Where are you seeing that? Is that just something you know because you've been through this and can look up what the policy states exactly? Does this mean it's carte blanche to have bariatric surgery as long as I'm Morbidly Obese?

@Soonerjoseph, Dude, slow down, take a few really deeeep breaths LOL...and when you get time, go and read some of the 100's of posts (1000's if including former sites) that Diana, Larra and MANY other Vets on here have previously posted and how they have helped people with WLS, but in particular with Diana regarding Insurance. Not to be presumptuous, but their time is very valuable and you can do a lot of pre-reading on your own to answer some of those basic questions, in particular the question you asked above I highlighted in red. I/we, YOU are so very lucky to have all their expertise and DECADES of experience at our disposal. They know what the F*@* they are doing!! The good news as I see it, it sounds to me like your insurance will cover the DS. That wording is very similar to mine, you just need to slow down and re-read it slowly a couple times. As @chevtow was saying, it sounds like to me that Morbid Obesity IS covered for the DS under your policy. What they mean when referring to “experimental” is a cure for Diabetes etc which the DS is actually done in Europe as a cure even in the non-obese.

Anyway, welcome aboard and my best wishes for your success. Rob

 

[marissamast]

I have BCBS of NC. That is how my guidelines read also. My PCP looked at them for me about a year ago and explained it to me just as Diana explained it. Then, in 2014 I developed medical issues, I had oxygen for 5 months after my breast cancer surgery, I developed diabetes, and I was having chest pains. When I decided on WLS, I went to all my Drs and spoke to them about it. Everyone of them agreed it would be a good idea and wrote me a letter for the insurance. It was only about 40 days from deciding I wanted it to my surgery date. I only had to see a NUT one time and have a psych eval and that was it. I spent all those 40 days on web sites like this one deciding which surgery I wanted and told my surgeon I wanted the DS when I met with him about 10 days before my surgery date.