warrior68

I have excellus BCBS Blue Point 2 insurance here in NY, I have been denied again, stating that the sleeve is exploratory / investigational. I am going to appeal the denial, and was wondering if anyone that has any type of BCBS Insurance that was approved for the sleeve to please post here with which company you have, what state you live in, and when you were approved. My thinking is that if I can provide a list of BCBS entities that have covered the sleeve, Excellus BCBS Blue point 2 could hardly then state that it is experimental or Investigational. I posted this in a couple different threads hoping to have as many people as possible see it, sorry for the over posts.

I would like to know if a patient has had Crohn's disease for 15+ years, and it has never traveled out of the intestine, and is very well controlled with Meds (6mp) that are not anti Inflammatory, is the sleeve a safe procedure? Long story short I spent almost a year battling with Insurance to get the lap band because my surgeon said it was the only way to go with a Crohn's patient. After months of arguing with insurance, my surgeon says he was lead to believe by the insurance company that they would approve me for the Sleeve. Although my surgeon says it would be a one a million chance that the crohn's would get in to my stomach, he still maintains that, while he will do the sleeve if approved, he feels the insurance company is wrong, and the band would be the best way to go. Just wondering what another Doctor would have to say about this as medical professional, whether it be just an opinion, or medically proven. Thanks Doc

I'm sorry guys, I forgot to come back and update this post, but I did update the other post. I was approved a few weeks ago, and will be having surgery on march 1st at 8am.

Got my approval from BCBS yesterday, saw my surgeon today, scheduled for 3/01/11, of course there is a bunch of pre op appointments, endoscopy, bla bla bla.... Bottom line, Im gonna get to be skinny before 2011 ends, ok maybe not skinny, but skinny enough! I have to say a big thanks to Dr DiBenetto and his staff at Bariactrics of Western NY. There were times during this process that I was not the most pleasant person to deal with due to all the insurance denials, but Dr D's Staff, especially Lorie stuck with me and got me approved.

Have your surgeon put in for approval, if you get denied appeal it, and dont give up! I Had to keep pushing for damn close to a year, but I finally got approved just yesterday.

Well, it took a year of fighting, screaming, yelling, jumping up and down, 3 denial letters, 2 request for additional info, 1 last denial for Exploratory / Investigational, and one last appeal... I received a phone call from my Customer Service rep at BCBS, they are tired of arguing with me, and have approved me for the sleeve! I called my Surgeon, we set a appointment for tomorrow morning to go over everything one last time, and set a surgery date!! Hell yeah!! I feel like I won the lottery. Anyone else who has been denied by Excellus BCBS Blue Point 2 in NY for Investigational / experimental reasons, they will not being using those terms to deny people any longer. Thanks to all the people here who posted appeal letters, that I stole / used portions of during my process. I'm so damn Happy I could do back flips.

Ok, so Today I will pick up another appeal letter from my PCP, that is supposed to be very strongly worded, My Surgeon, and his partner have both written appeal letters for me. I personally used a copy of Zenbunni's Appeal letter modified for my situation, and I wrote them a very personal letter explaining why I felt I needed the surgery. My surgeons office is handling the appeal for me, so I sent both the letters I wrote to them, and told them to use whichever one they liked best, they called back and said they were both outstanding letters, and they were going to submit both with the appeal. Today I will pick up my appeal letter from my PCP, and get it to my Surgeon, then Friday everything will be submitted to Excellus BCBS Blue point 2 under the expedited two day appeal process for hopeful approval. If nothing else, even if they deny me again they are going to have a lot of reading to do, 5 letters in total, and they will have to be more specific than, denied due to exploratory / Investigational. I am trying so hard not to get to excited, like I do every time we submit for approval, but its gotta work this time, right? If It doesn't work I'll keep pushing until it does, but I sure would like to have this surgery sooner than later since I been screwing around with several denials all year long. I have to say when I first started this whole WLS process I thought it would go so much quicker than it has. I had all the dr visits done, clearance letters from the food shrink, nutritionist, support letter from PCP, and the needed weight loss done in just a couple weeks. It has been about a year of constant arguing, re submitting, arguing more, getting denied again, switching surgical procedures and re submitting, more denials. UGHH I'm thinking they have to give in at some point. Thinking back when I first met my surgeon we were looking at a June or July surgery, then denied, then we hoped for a Sept, Oct surgery, Now I'm watching December come and go very quickly.

Yesterday I spoke to the Nurse that handles all the appeals at the surgeons office, it seems as though everything is in line to be submitted today. The nurse, the surgeon, the surgeons partner, my pcp, and myself have all written letters for the appeal, My PCP wrote right in his letter than risks of not having the surgery, far out weigh any any possible risks associated with the surgery itself in my case. The Nurse at the surgeons office feels like there is almost no way they can deny me again, but having been there, heard that, seen that movie, read that book, I'm not gonna believe it this time until I get a approval letter in my hands. Everything will be submitted today, we are shooting for a expedited approval which only gives them 2 business days to review and decide, however if they dont accept it expedited they then have 30 days to review it and decide. I'm hopeful that I will have some news regarding a decision by Tuesday evening, or Wednesday morning. For now I just sit, wait, wonder, and stress over it, lol.

Good luck with the approval. I have Crohn's disease too, and it has been a long process getting approved, first we tried for the band, got denied, then resubmitted for the band, got denied again, changed to the sleeve and got denied because my Insurance felt it was exploratory / Invesitagtional. I will be submitting my appeal on Friday, and feel like this time we may get it through. What insurance do you have? What state are you in?

Wow, that is a great letter!! I do plan on using it, thank you so much!!

Thank you everyone for the replies. I Plan on filing my appeal before the week is out, but may have to hold off until the beginning of next week. Long story short here, I was denied for the band back in June because I have a intestinal disease (Crohns Disease) BCBS stated they were afraid of erosion due to the band. We resubmitted the request two more times, My surgeon and I did some research, and neither lap band company was willing to help out with a appeal for a Crohns Patient. Basically there is no evidence that the band in a crohns patient would cause problems, but there is also no evidence to show it wouldn't. Fast forward to Oct when I all the sudden I had a temp loss of vision, my BP spiked sky high, my sugar levels went through the roof. My PCP then tells me, you are a train wreck waiting to happen, and if you dont lose this weight and keep it off for good you may not be around much longer. I go back to the surgeon, we talk things over and he says, the sleeve is safer, and he can get me approved for the sleeve, we put in the request, and it got denied stating that it is experimental / investigational. I have a list of co morbidity's a mile long High blood pressure Type 2 Diabetes Obstructive sleep apnea Acid reflux High Cholesterol BMI of over 46 I have a proven med history of weight loss and re gain. And the Dr says I am a high risk for a stroke right now. I have completed all the pre screening Dr visits, I lost more than the required 5% . I started out at 5'7" 318lbs at my first visit to the surgeon, I now hover around the 298 -303 lb area. My PCP is going to write a much stronger worded letter of recommendation than he did last time. I have written a letter myself that I plan on adding a list of all the BCBS divisions or entities that do cover the sleeve before finalizing it, and my surgeon and his staff are pursuing this on their end too. The nice lady that handles the insurance end of things at my surgeon says she did get one through Excellus BCBS Bluepoint 2 a couple weeks ago due to Rheumatoid arthritis, which I also have. I'm unsure what the Rheumatoid arthritis has to do with it, but it does make me somewhat hopeful. I think the angle I'm shooting at is that a precedence has been set by approving it through other BCBS policies, especially BCBS Federal. Why in world is it ok for a Federal employee to get the sleeve, but yet its considered exploratory / Investigational for a non federal employee? Sorry I have a habbit of rambling on when it comes to this. I'm trying not to get to excited about being approved this time, as I hate the huge let down when I get those damn denial letters Thanks for all the replies!

I'mso sick of this crap with BlueCross Blue shield. When I first went in to my surgeon the receptionist, and the doctor were both like, "Wow you have great Insurance, approval will be easy, they approve everyone". Three denial letters latter here I sit. BlueCross has these Medical Directors that make all the decisions regarding surgery, but the medical directors will not speak to policy holders. How can a person make life altering decisions on my behalf without even speaking to me??!!! After the second denial I had a sudden loss of vision, my BP went up to 190 over 110, and sugar number were through the roof, and I had four more meds added to my daily pile of pills. I go back to my surgeon who tells me, well now they have to approve you with all that just happened. Well I just got my third denial letter today, the reason this time, the sleeve is still considered by BlueCross BlueSield to be experimental. I have contacted my Legislators, and Senators regarding Health care laws and medical directors that are not accessible to policy holders, but that was weeks ago. I just send BCBS a email explaining that I feel they are trying to kill me, rather than pay for the surgery, and I will follow up with a call on Monday. I have no clue what else to do, I guess I'll just keep taking daily meds and getting sicker and sicker, and hope that I can get approved before I end up having a friggin heart attack. Sorry, just had to vent.

Thanks for all the posts, I will definitely check out that attorneys website. I did have my Primary care Physician write letters to BCBS, three of them. MY PCP stated all my Conditions, and said that he believed that WLS was the best option I have at living a long healthy life. In each letter he wrote down my weights at different dates over the years- I have always been able to diet, lose 40 to 80 lbs quickly, but then it comes back with even more. When I emailed BCBS yesterday, because there customer service was not open to receive calls a few of the things I mentioned in the email were. They had medical proof that I was headed towards a hear attack, or stroke, yet they denied me for a procedure stating not med necessary, and that shortly after that denial I damn near did have a heart attack or stroke, with a temp loss of vision, elevated BP and sugar levels. Now they have more med proof that I need the surgery and they still wont cover it. I pointed out in the email that with all that is going on in this country with health how would it look for BCBS if I were to contact all my local news channels and explain how my insurance company is denying me a med procedure that will save my life. I further went on to explain that as of the close of business on Monday if have still been denied access to this "Medical Director" that is denying me stating they only talk to Doctors, well they will then have two types of people Medical Directors speak to, Attorneys, and Doctors. I was so pissed yesterday when I received that letter, I haven't been that mad in a long time, and of course I had nobody to vent to because I haven't told anyone I'm having surgery. This has been a very long process / fight for me, and each time I see the Surgeon and he tells me that, "dont worry I'm gonna get you approved" I get so excited, and feel like I'm on top of the world! Without fail A few weeks later, wham the insurance company sends another letter stating that they are going to cheap out and deny my surgery. I have asked them on the phone, if they would have preferred that when I damn near had the hart attack, that I would have just died? No surgery cost, no meds for life, they win, right? Sorry, I'm rambling on and on again, I must still be more mad than I thought I was when I woke up. Thank you everyone for your support and great post.

Hi everyone, I'm new here and have a few questions. I have spent the past few months, almost a year on lapbandtalk.com forum because that was the surgery I wanted, and at the time the only one my Surgeon would perform on me. My surgeon was admit that because I have Crohns Disease the only true safe WLS surgery would be the band, or maybe an outside chance at the sleeve, but he felt best about band. Obviously at that appointment he gave me a list of stuff to get done before he would see me again, lose 18 lbs, see the food shrink, see the nutritionist, see the Diabeties dr, and all the normal WLS stuff. The Dr had told me it normally takes 6 moths to a year to complete the list, and get the ok from all the different doctors, Nutritionist and so on. I lost the 18 lbs in 10 days, and had all the doctors signed off on this within 3 weeks. When I went back to see my surgeon nobody at his office could believe I completed the check list that fast, and they put in my approval request for Band surgery. My insurance, which is good insurance, and the dr office says approves damn near everyone denied me, stating they needed more information. I gathered up all the info my surgeon told me to, it was resubmitted, and denied stating not medically necessary at this time. The surgeon then resubmitted the request, and it came back denied, Due to Crohns disease, and requested my surgeon call the med director at Blue Choice. Turns out the insurance company is worried about corrosion from the band, and with Crohns this could be really bad. My surgeons stance was that the band is really the safest way to go because if the crohns flares up they can drain the band, or even remove it if really needed. Long story longer, I got denied again, I called Blue choice Insurance myself, and asked to speak to the med director and was told they only talk to doctors, not policy holders. I have called Blue choice three and four times a week for months now, they still wont give in and let me speak to a med director. I would think as a paying policy holder I should be able to speak to the person who is making med decisions regarding my health, right? My surgeon keeps pushing too, without much luck. Last week my surgeon calls me and says come in tomorrow I need to talk to you. I go in to the office, and the girl behind the desk tells me, no charge for today, doctors orders, ok great, a free bee. Instead of taking me to a exam room they walk me to the surgeons office, and he says have a seat, at this point I'm thinking oh crap, he is gonna tell its all over and no surgery at all for me. I was amazed at what did actually say, and confused by it at the same time. The surgeon proceeds to tell me that if I agree to switch procedures he has been lead to believe that the insurance company will cover me for the sleeve. This really blows my mind! I have crohns, which is a mouth to anus disease, meaning it can show up anywhere between those two places. While my Crohns has been restricted to my Intestine, and has not been active, it is always a concern, which is why I can't have the full bypass. My Surgeon says we can most likely move forward very quickly avoiding the 6 moth wait for the sleeve due to the fact that I have been in a holding pattern for almost a year now. I want to get this done ASAP, but I also want to know what I'm walking into, so I'm going to continue to read every damn thread on this board that I can right up until surgery. I have spent the past six days reading online about the sleeve, and trying to research the sleeve with Crohns patients, but I can not find any info regarding the two of them together. Does anyone on this forum have crohns? If so how is the sleeve working for you? Has anyone heard of someone with crohns having the sleeve? Has anyone here had the band and switched to the sleeve? Would you get sleeved again if given the choice? Any input would be greatly appreciated. Thanks

Thank you for the reply, I will definitely ask the question in the "ask the doctor" forum. At the time I posted I was extremely Excited, or irritated, maybe a bit of both. I had been told that the band was the only thing I could have, and that how long it would take to get the band depended on how quick I completed my list. I busted my but getting that list of stuff done in just a few weeks, all so I could spend damn near a year arguing with the insurance company. I spent countless hours researching the band surgery, and then WHAM, guess what, you can only have the sleeve! The sleeve, WTF is the Sleeve??!! I had heard of the sleeve, but had no clue what it was, how it worked, or how it compared the band. I had been told the band was my only option, so why would I research the sleeve?. Being a person that likes to research for myself, and in this case hear from others that have been there, done that, here I am, and I'll be here daily reading and researching. After doing a lot of reading on this forum, and reading everything I could find on Google, I am now almost kind of glad that I may be getting the sleeve. It seems as though in the long run, once the stomach is healed the sleeve may present a lot less problems than the band, and no playing around with, fill, un-fill, fill. Now I just hope that I can get approved for the sleeve, I need this surgery so bad for health reasons, and I'm getting tired of playing around with the insurance company.

I'm wondering if anyone here has Crohn's disease?? I am having a very difficult time getting approved because of my Crohn's disease. My surgeon wants my to consider getting the sleeve Instead, he says that Insurance is more apt to allow it. Does anyone have the sleeve, or know anyone with the sleeve? I'm so beyond Pissed at my med insurance provider at this point, uggh its driving me nuts!! I call Blue Choice, and they say well its the med directors decision at this point. Naturally I ask " Can I please speak to the med director?" The lady on the phone tells me, med directors dont talk to subscribers, only doctors. I tried to explain that I am a paying subscriber to their service and feel that I should be able to speak to the person making choices regarding my health, I got nowhere with it!

Im wondering if anyone here has Crohn's disease?? I am having a very difficult time getting approved because of my Crohn's disease. My surgeon wants my to consider getting the sleeve Instead, he says that Insurance is more apt to allow it. Does anyone have the sleeve, or know anyone with the sleeve? Im so beyond Pissed at my med insurance provider at this point, uggh its driving me nuts!! I call Blue Choice, and they say well its the med directors decision at this point. Naturally I ask " Can I please speak to the med director?" The lady on the phone tells me, med directors dont talk to subscribers, only doctors. I tried to explain that I am a paying subscriber to their service and feel that I should be able to speak to the person making choices regarding my health, I got nowhere with it!

Ok so was going to order some Isopure zero carb Protein drinks to see which flavors I like best. I have come across a dilemma, Im not sure if people on here are talking about Isopure or Natures best Isopure? They are both zero carbs, and are both wicked expensive, but they seem to be two different manufactures, both can be found on amazon.com. I'm wondering if it makes a difference as to which one I use? I have posted links to both websites. Protein Drinks | Isopure Nature's Best To me they seem like the same thing, except one is 6oz, the other is 24 oz, and Natures best comes in way more flavors.

I got a letter from BC today, not a Approval, not a denial, just a screw you we think we'll take our time and break your balls about this surgery kind of letter. The are requesting additional information because I have Crohn's disease. I called them and they I am told that they want to make sure my Dr and Surgeon know I have Crohns, and still think Lap band would be a good choice. I Explained to the lady on the phone, Of course my primary physician knows I have crohns, and you have a letter he wrote saying He supported my choice to have lap band surgery. Well sir we it needs to be reviewed by our med director now. Ok mam, could I Please speak to your medical director? Um no sir you can not, they do not talk to people. Excuse me, are you saying that your medical directors who's salary the policy holders pay, will not talk to the policy holders? Yes sir, they do not talk to policy holders. Bc has left me no choice but to be a constant pain in there buts every minute of every day until they approve me, every time thought out the day that I get an extra 2 minutes I'm going to call, and ask to speak the medical director. Damn Im figgin Pissed!!

I haven't told many people at all that I am going for the band, only a few close family and friends. I just love how everyone, especially the skinny people know absolutely everything about the lap band, and oh by the way any information I have obtained is 100% wrong, and misleading! LOL I spoke to one friend tonight that told me by pass and the lap band are the same thing, and that the lap band is not out patient surgery, and that I would be out of work for minimum of 4 months. My friend got this information from his wife who is nurse, so nothing I said mattered or was valid. My buddies wife also told him that she knows a lot of people who have had WLS and they all say they would NEVER do it again. I tried to explain to my buddy that I have done a lot of research and that he may not like it but either he misunderstood what his wife told him, or she was just flat out wrong. I went on to explain that out of the 10 or more people I have met in person who have had WLS only one of them said she felt is was trading one problem for another. The one person I know that was unsure if she would do it again had band surgery 15+ years ago when it wasn't even called a band, she has what she calls a ring around her stomach with no fill port. I'm not sure why so many of my family and friends are so against this? My one closest friend seems understand, and to my surprise has had nothing negitive to say at all, which is amazing is you knew him. I know this question has been on here before, but just for reassurance reasons. If you were in the same set of circumstances you were in when you got the band the first time, would you get the band again? I am only asking this question so I can go back and tell the nay Sayers that amount of people responded, and X amount said they would, and X said they would not do it again. Thanks

I think I just answered my own question after some more research. It seems like the Isopure Company owns, or is Part of the Natues Best Isopure company, I found that on the contact us link, one the of the email address's listed was natures best isopure, and one was isopure. The difference between the drinks seems to the physical size, and the Natures best has potassium in it, and the Isopure doesn't. Which one do most people buy?

Ok, now that I have calmed down a little bit, this still sucks. I just cant believe that they are so insane as to believe that my own primary doctor of over 18 years wouldn't know I had crohns at the time he wrote the support letter. I work in the insurance industry as a adjuster, and I always try to look at things logically, however I also understand that with insurance everyone has to always cover their ass 100% of time. I guess I'm just frustrated that they would let me get this far in to the process before saying "hey we need your doctor to say this". At this point time is so important to me, right now is my slow season if it gets past September I'll have to put it off till next spring and go through all the BS again. I'm gonna make some phone calls tomorrow and see what I can do to speed up the process, maybe have my gastrointerologist fax BC a letter, since he is the one that deals with my crohns issues. Hmmm ahh well, hurry up and wait! LOL

I was so Focesed on getting down to weight, and quiting smoking for my second appointment with the surgeon on 5/27/10. Nobody in the surgeons office could believe I actually went to all the appointments and lost the weight that quick, in fact when I called to schedule the follow up they acted as though there was no way I had everything done. I met all the goals the had told me to, and they submitted my request to the insurance company, and told me to just maintain the weight loss until the surgery date. I left there thinking wow that was easy, now all I have to do is maintain the loss. Well that weekend was Memorial day weekend, of course there was a family picnic, lots of awesome chow, then another picnic with friends and of course more good chow, the next weekend friends came to visit from out of town, so of course more good chow. As I was going to these picnics I was thinking, I have always been able to lose weight really quick, so If I gain a pound or two, no biggie.. Well I completely lost sight of the goal, and today almost three weeks later I weighed myself, at almost 15lbs over the weight I needed to maintain!! I am so scared that the doctor will call and say, hey we got your approval, come on in to weigh in schedule your endoscopy and your surgery. I started back at the gym today, and am going back on a 800 to 1000 cal a day diet today. I know there must be a few people out there that have mad the same mistake? Does anyone have advise on getting the 15lbs off very quickly? I'm OK with quick gimmick diets to get to my goal quickly, and through working out, and eating less I'll maintain the weight from there, I will not let myself slip again! I am so MAD at myself right now! Seems like I did all that hard work for nothing right now.

I went out and bought WLS for dummies, mainly because I figure while I am in the Insurance Holding pattern I may well ready everything I can find on Lap band Surgery. I realize the book was published in 2005, so the info may be kind of out dated as I am sure a lot has changed since 2005. One things I read in the book, in more than one place is that Lap Band patients do not experience "Dumping" because all the intestines and stomach are left in tact allowing for full absorption. Now I know everything is left in tact, and that's why I have chosen lap band surgery over the bi-pass, but it was my understanding that "Dumping" is still a issue with the band. It would be great if a few bandsters could clear this up, do you experience dumping when eating to much sugar?

Although that's not the answer I was looking for, it most likely the correct one!