spalm

Hi, I am new to posting here and posted in another forum but think this is where I belong posting my question. I know there had to be posts in these forums on this same topic but I cant find them I have BCBS of Delaware. My husband works for the union and it is self insured. BSBS at first told me that WLS would be covered if it was a medical necessity. Also, that WLS would be covered even if it was an exclusion on the policy. They gave me the criteria I had to meet and told me to have my doc submit all the paperwork. I called today and spoke with a different rep from BCBS. She said that it wasnt covered. She even called my husband Employee Relations office to double check. She called me back and said no it wasnt covered. I even called Employee Relations and they told me the same thing. :help: Has anyone else had this same situation and able to still get approval? If so, what did you to? It just seems hopeless!!!! It is truly amazing how a group of trustees can decide something like this. It just baffles me that someone who may a in a life or death situation and needed something like this done immediately that they can just say sorry its not a benefit. Whats this world coming to?

Hi everyone!! This seems to be a good support group. I am hoping to get to know you all and to eventually be able to give information to someone new like myself to help get started and to give my support. Everyone here seems to be a big supporter of each other and sticks together. Thats AWESOME. I am new to ALL of this lapband stuff. I have for a couple of months just read some posts on this site and have been playing with the idea of getting it done for myself. I know its a long process but am wondering if someone would be so kind as to tell me where to start. I believe I have enough ailments. To many to mention right now. I do know that I should fit in the catagory with the BMI of over 40. I have over 100+ lbs to lose. I have BCBS of Delaware. Does anyone know what you have to do about getting your insurance to cover it? I have heard some post say its no problem to have BCBS cover this procedure and other post say they wont at all because the procedure is experimental. First off I have looked into some Doctors Dr Schweitzer in John Hopkins in Baltimore, MD Dr. von Ruedon in Baltimore. Dr. Ingau in Delaware 1. WHERE do I BEGIN? 2.Where is the best place to get research on this? to tell me the steps I need to take to begin 3. Does anyone know what the success rate is with these doctors? 4.Has anyone had to deal with BCBS of Delaware to get this procedure covered? If anyone can help I would appreciate it. If you need to you can email me direct. Thank you.

Well heres an update- I went to my PCP and he said he would write a letter and do what he could do to get the insurance to approve the surgery. Well, I wanted to get better clarification on my policy. Even though I was told that BSBS would cover the surgery if the above cirteria that I wrote earlier was met. Well thats true but..... with the exlusion that my husband has on his policy at his job stating anything weight loss related will not be covered even if recommended by a doctore the surgery will not be covered. BCBS call my husbands Employee Relations office to clarify it for me. Then I called and was told which I had heard before. If the Insurance is self pay through the union then whatever they have in their health benefit policy over rides what BSBS says. So a team of trustees decide your future even though your doctor says its medically necessary. Crazy or what??? Anyone have any suggestions?

Hi everyone, I just wante to follow up and tell you what I found out. So it is encouraging for others if they are in the same situation. I called BCBS of Delaware this morning. I was told that my insurance does not cover anything that is diagnosed for obesity. Also, my husband policy at work states what I mentioned above. When I told the rep that my primary doc is suggesting that I have lapband surgery. Thats its not just for weightloss although that would be nice but for health issues she put me on hold for awhile and came back with these conditions. She did say that these are not a guarantee of benifit coverage until my doc calls the referall center and everything has to be precertified even though my insurance does not requirie me to get pre authorized. I guess this case is totally different. She also said that it doesnt say in her list but she does know that get a cardiac clearance and a pshy evaluations is also required. But this is the qualifications that she said: 1. covered if medically necessay 2. attempted and failed at some sort of weightloss for 1 year. She said conservative measure for one year. Does not have to be the past year. (I asked if it had to be for 2005.) 3. have 1 of these: hypertension a BMI of over 35 for more than a year but must be at least 40 now sleep apnea Type II Diabetes Degenerative Joint Disease coronary arteries 100 + overweight I know I have been reading some post that your insurance will tell you one thing and then at the last minute they'll throw someting else in there. They didnt mention about seeing a nutrtitionist for 6 months. So I am actually expecting to hear that needs to be done also. It would be nice to post what some may have had to do before being approved so others can jump ahead. Hope this helps someone. I guess the biggest thing is even though my husbands benefits say no to weight reduction even if recommended by a doctor - that may not always be so cut and dry so its still worth it for anyone to look into. So crossing my fingers..... If anyone knows of something else the insurance has been known to throw in there please let me know. Thanks

No I know they wont cover them because when I was pregnant I had gestational diabetes and the nutritionist that I had to see was not covered. Luckily I controlled it with my diet of low carb and didnt have to go back. my gyn watched it and I monitored with the glucose monitor. but... I think that would be worth paying for if the insurance did cover the procedure. I will definitely call in the morning and will keep everyone posted. Hopefully help someone else also..

I am not only trying to fight for myself but after suffering from PCOS and having fertility issues we have a 15 year old son and now have a 10 month little girl who I want to be able to enjoy life with her instead of being on the couch in pain and watching. It really is depressing!! I am 40 years old and hope I have many years left. Yup I am over the hill!! LOL ahhhh a loop hole is it??. Actually it says in my plan book: services and/or drugs in any way related to weight reduction, whether or not recommended by a physician Whats your take on that? It sounds to me any kind of treatment but if my doc puts morbidly obese than maybe??? I am going to call tommorow and see what my insurance actually says before I contact my husbands local union.

Hi Cristina, Thanks for the information. I believe I have a long road ahead of me with the insurance. My husband works for a union in Delaware. I looked at his policy book last nite and anything related to weightloss whether recommended by your doctor is NOT covered. I was told that I would need to appeal to the board of Trustees to try to even approve this procedure since the insurance is a self pay through the union and like you said many may have the same insurance but some employers may purchase a cheater version of the plan. Anyone else have this same experience that could give me a sample appeal letter. I know they have approved different cases for infertility even though any type of infertility treatment is also NOT covered but you need to write a letter and in some case they have been known to provide some type of coverage. It so frustrating when you pay for the insurance but yet they decide what they want to cover and to make exceptions for whoever but I am not going to give up. I dont know how many letters I can write but I am prepared to keep fighting (strong word) it. Thanks