kathywb

Wendell, help. First time on this site. Banded 12/8. Have a 14cc Lapband Dec 2008. TEN FILLS later at 9.6 cc full. Little restriction no sweetspot. 62 years old. Feel I'm doomed to slow weight loss - can walk, no extreme exercises. Small fills each time. 50 lbs first year - 1 lb a month since - total 58 in 15 months. 40 to go at least - aiming for size 14. Frustrated. Got reflux more than .4cc fills. Kathy B

1/7/09 I had emailed before my surgery re denial by BCBS - maybe some of these facts will help someone. I appealed BCBS decision and got ok in 5 days because, even after doing everything right, the nurse at BCBS who picked up the fax with all my records FOR APPROVAL via my surgeons office said my 6 visits were only 5 and thats what she said to her director at BCBS (there are many). This is happening at BCBS in Newark, NJ. I dont know if they do the whole country or just NJ. I think my particular surgeons office is now requiring 7 months because of this which makes no sense. Something needs fixing. I called and spoke to a nurse in Appeals who agreed with me - I re-sent my primary's letter detailing the six month weight loss (and 5 year annual weights, copies of 6 month notes, and his recommendations and concerns). She passed it on thru with her ok to her Director. I started my six month weight loss plan before I settled on a surgeon. Yes it has to be within the last 12 months. You may be able to use WW records within the last 12 months but you have to check. I'd rather do once a month in dr's office for six months. My BMI was 46 I had high bp, high cholesterol - no apnea, diabetes. I may be wrong about this - but I think if you go to a surgeon as a lapband OUTpatient the rules via BCBS might be eased. I was obviously an inpatient. Good luck and thanks to everyone for their help. KB

Thank you - I had checked there yesterday but couldn't find where to go - but after your email I tried again and put in a query and I think I found what I need "How to File a Utilization Appeal". Thanks again. I was hoping to find some blogs on people who were denied but wasn't successful - any ideas?

My paperwork was sent in and in 5 days I was rejected by bcbsnj - they said i only went to five weight loss meetings when my drs notes and letter clearly says six. I'm hearing they are now going to ask for a consult with medical weight loss dr/nutritionist plus six visits. Something is changing. I've emailed my surgeon to please appeal for me. Did everything else timely - even have medical release done, etc. Anybody hear anything about this? Thanks.

Help! My surgeon just submitted everything to bcbsnj for lapband - my primary's ltr of med necessity. 6 months of visits (3 lb loss) with drs notes of weights and 6 month history of nutrition, exercise, behavior modification; 5 year weights; bmi high; high bp, etc. Did all the psych, rehab visit, nutrition visit. I WAS DENIED. I'm devastated. We're going to appeal. I was denied because they said I have 5 visits - BCBS I think is trying to say first visit is just a consult for weight - you need 6 after that. In other words, they may be changing the rules - and I'm a victim. I did everything right. I already have pre surgery stuff done and to surgeon and date set in 3 weeks. Help!

11/24/08 You want to talk about pulling hair out? I did everything right with BCBSNJ and they just denied me. Said I only had 5 visits and I had 6 visits, which was detailed in letter. I'm appealing. They're changing rules. I'm devastated.