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Tuesday, October 03, 2006

Like Buying a House!

Okay, so like when did buying a gym membership seem like closing paperwork on a home? While everyone was nice at this particular 24 Super Sport we signed up at, it took forever! I'm totally pumped though (no pun intended). I have my first training session today, and this girl is going to be building some muscle. ;-) I want to be ahead of the curve when I am threatened with losing muscle mass before surgery.

So in other news, I kind of read in a few different places where some were speculating that Blue Cross Blue Shield of TX is changing their requirements for bariatric surgery. I went out to the provider side website and indeed found the policy change that was effective 9/1/2006. Now it requires a 6 month, instead of a 12 month medically supervised diet. Of course me, being who I am, won't allow myself to get too excited. I sent an e-mail to B, the surgeon's office manager, and she said it was good news, but that each employer will still use a case-by-case basis. Ugh.

For anyone using BCBS of TX, here's the policy change from their website:


Title: Surgery for Morbid Obesity
Number: SUR716.003
Effective Date: 09-01-2006

Contract: Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.

Members and their providers have the responsibility for consulting the member's benefit plan or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern.

Coverage: Each benefit plan or contract defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply.


The following criteria and guidelines have been developed to judge eligibility for coverage of bariatric surgery for the treatment of morbid obesity.

To be considered eligible for benefit coverage of bariatric surgery for treatment of morbid obesity, the following three criteria must be met:

A. A diagnosis of Morbid Obesity, defined as:
* Body Mass Index (BMI) of greater than or equal to 40 kg/meter squared; OR
* BMI greater than or equal to 35kg/meters squared with at least two (2) of the following co-morbid conditions which have not responded to maximum medical management and which are generally expected to be reversed or improved by bariatric treatment:
* Hypertension,
* Dyslipidemia,
* Diabetes Mellitus,
* Coronary heart disease, and/or
* Sleep apnea.

[Note: A BMI formula can be found in the description section of this policy.]

AND

B. At least a five-year history of Morbid Obesity supported by medical
record documentation.

AND

C. It is expected that appropriate non-surgical treatment should have been attempted prior to surgical treatment of obesity Non-surgical treatment of morbid obesity appropriateness criteria:
Medical record documentation of active participation in a clinically-supervised, non-surgical program of weight reduction for at least 6 months, occurring within the twenty-four (24) months prior to the proposed surgery and preferably unaffiliated with the bariatric surgery program.

[NOTE: The initial BMI at the beginning of a weight reduction program will be the "qualifying" BMI used to meet the BMI criteria for the definition of morbid obesity used in this policy.]

A program will be considered appropriate if it includes the following

components:
* Nutritional therapy, which may include medical nutrition therapy such as a very low calorie diet such as MediFast or OptiFast OR a recognized commercial diet-based weight loss program such as Weight Watchers, Jenny Craig, etc.
* Behavior modification or behavioral health interventions.
* Counseling and instruction on exercise and increased physical activity.
* Pharmacologic therapy (as appropriate).
* Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health.

3 comments:

Danyele said...

That great news for anyone with BCBS of Texas. I can't imagine having to go through a 12 month diet program before being approved. I was pretty lucky with BS of California. BTW - I just got the statement of charges for my surgery - my insurance was billed $79,000!!! That in itself is motivation to follow the rules and take care of my new tummy.

Dagny said...

I hope this will make things easier for you Donna and you'll be able to get a date SOONER! Good luck!!

SignGurl said...

Hi Donna! Looks like we are both in the insurance trap for WLS. It's so disheartening.

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