BCBS = 1 ; Patient (me) = 0

[2beskinny 4]

Well, I was denied coverage today :thumbup:. I initially thought I would self pay, then was encouraged to submit to insurance, but I told myself I would self-pay if I was denied. Well........now they say a 3 month diet (my surgeon's staff thought that my 5 mos. of ww as well as all my other weight loss attempts might be enough to get it approved. They are not discounting that, but want to see proof of lifestyle change, nutritional counseling, exercise, behavior modification...ummm....how does ww provide proof of those things:confused:? I called my doctor's office and told them what was going one. They, of course, are familiar with this tactic (yes, I said tactic). She said she could count my initial consultation as the first visit, they booked me an appointment for tomorrow and will be conducting my supervised diet (giving me credit for one month already, I guess). I am so thrilled with their level of responsiveness and caring. Now I have to ask myself if waiting 2 more months is worth it. Yes, I have to say it is. Guess I will be starting my diet for real tomorrow. Since I'm right at a 40 bmi, they recommended that I did not lose any weight till my approval came through. My insurance company has assured me that they only consider the initial weight for this purpose. I know my doc's office is just being cautious as I'm sure they have seen it all. Feel like I have lucked out in a way...my insurance person that I've been speaking with is also waiting for lap band approval and has been above and beyond nice to me. She's giving me good advice on the whole process. I'm not looking at it as a big disappointment though (turn that frown upside down!)...Since I've been trying not to lose any weight, I've been treating every meal like the last supper and quite frankly I'm just over it! I gained a few more pounds in the process and I just want to start this phase of my life. If it begins with a three (two) month diet, minus the band, who cares? It's all weight that needs to come off. I know I can lose weight - just can't keep it off. I'm also considering taking phentermine to jump start everything. I was seeing a doctor last year who prescribed it (lost 25 lbs!) and as long as my surgeon is ok with it (I'll ask tomorrow at my appt.) I think I will go that route since I know there is an end in sight. Thanks for listening to my ramble...just had to vent!:thumbup:

[perryjoyce 0]

You should definitely wait and let insurance cover it for one simple reason: if insurance covers it now and you have complications down the line, insurance will cover the complications. If you self-pay, insurance will NOT cover anything! For me it was worth that bit of comfort and security knowing that even if something goes wrong, I won't be stuck with the bill.

Two months is really nothing especially if you can schedule your surgery for right after. I started this process almost exactly two months ago and my surgery is a week from today. I was the most impatient person in the world when I was first starting out and I had no idea how I was going to "suffer through" eight long weeks. Let me tell you, it FLIES by! So please, don't let the two months stop you.

It's also worth learning patience now because from what I hear, the first eight weeks or so after surgery are dedicated to slow healing and recovery. So if you're already in a rush and you go into that period equally in a rush, you will probably only frustrate yourself. That's my biggest fear right now, managing my expectations vs. my impatience! We'll get through it though! One day at a time, as they say! :thumbup:

[perryjoyce 0]

Also, I've been told time and time again that they only count your initial weight when you first submit your paperwork for approval. So if you lose you will still be eligible. It would be really stupid of insurance if they demand you go through a medically supervised diet but then penalized you for being successful!

[BetsyB 9]

You weren't denied coverage. You were simply told their "rules" for coverage. And that includes the 3-month supervised diet for which the clock starts ticking with the first weigh-in in the surgeon's office.

It's all spelled out pretty definitively in your insurance contract. (I have the same BCBS coverage.) Your surgeon's insurance specialist should have known that Weight Watchers records, or even records of monitoring by your primary care physician, would not be sufficient for BCBS, and told you this so your hopes would not have been raised.

I'm sorry you were disappointed---but the ball is now rolling, and you will be amazed at how rapidly the time goes by as you do all the hoop-jumping required preoperatively. (You will be busy doing things like getting clearance from a psychologist, having pulmonary function tests and seeing a pulmonologist and cardiologist, and so on.) Really, your surgery would not likely be scheduled any sooner if you didn't have to wait for BCBS approval---even self-pay patients have to get these clearances, and they take time.

Before you know it, you'll be banded!

[2beskinny 4]

You should definitely wait and let insurance cover it for one simple reason: if insurance covers it now and you have complications down the line, insurance will cover the complications. If you self-pay, insurance will NOT cover anything! For me it was worth that bit of comfort and security knowing that even if something goes wrong, I won't be stuck with the bill.

Two months is really nothing especially if you can schedule your surgery for right after. I started this process almost exactly two months ago and my surgery is a week from today. I was the most impatient person in the world when I was first starting out and I had no idea how I was going to "suffer through" eight long weeks. Let me tell you, it FLIES by! So please, don't let the two months stop you.

It's also worth learning patience now because from what I hear, the first eight weeks or so after surgery are dedicated to slow healing and recovery. So if you're already in a rush and you go into that period equally in a rush, you will probably only frustrate yourself. That's my biggest fear right now, managing my expectations vs. my impatience! We'll get through it though! One day at a time, as they say! :thumbup:

Wow, a week from today! That's awesome! You are totally right - it's worth it to wait for insurance. My doc covers 1st 2 years (fills, complications, anything necessary) and then you're right - you are on your own financially after that. Best of luck to you next week and the days to come...are you on a pre-op diet? Are you more excited or more nervous :thumbup: Good point on the rushing for weight loss and then possibly getting frustrated during the healing process. It would be nice to go into surgery 20 lbs less than I am right now anyway. I don't think I'd lose 20 on a 2 week pre-op

[2beskinny 4]

You weren't denied coverage. You were simply told their "rules" for coverage. And that includes the 3-month supervised diet for which the clock starts ticking with the first weigh-in in the surgeon's office.

It's all spelled out pretty definitively in your insurance contract. (I have the same BCBS coverage.) Your surgeon's insurance specialist should have known that Weight Watchers records, or even records of monitoring by your primary care physician, would not be sufficient for BCBS, and told you this so your hopes would not have been raised.

I'm sorry you were disappointed---but the ball is now rolling, and you will be amazed at how rapidly the time goes by as you do all the hoop-jumping required preoperatively. (You will be busy doing things like getting clearance from a psychologist, having pulmonary function tests and seeing a pulmonologist and cardiologist, and so on.) Really, your surgery would not likely be scheduled any sooner if you didn't have to wait for BCBS approval---even self-pay patients have to get these clearances, and they take time.

Before you know it, you'll be banded!

Yes - I read all that language in the contract as well. I was a little surpised that the staff person at doc's said they have been seeing approval on ww and jenny craig alone. But I think the pendulum is swinging in the insurance world towards favoring this surgery.

The approval guidelines have already softened. I figured the doc's office was ahead of the curve with their knowledge of what bcbs was doing. I still think they are, however, just not in my case. I'm sure it's very dependent on the team that is reviewing your case, etc. Not to worry...like I said, I'm not viewing this as a set-back, but a chance to lose some additional weight before surgery. My husband was a little relieved that I am not heading to surgery in a couple of weeks. I know he's not totally enthusiastic about this. Not to say that he is unsupportive, but he's nervous about it no matter how many times I repeat the statistics to him. He is a worrier and he loves me, so I guess I can understand. It's just that he cannot understand the struggle with food. He has one of those metabolisms that we all envy. He can eat whatever he wants and not gain weight. I think he might weigh 10 pounds more than when I met him 25 years ago. However, he does work out alot - always has. I think it's a combination of the two :thumbup: More time for him to get used to the idea, too, I guess!

[2beskinny 4]

PS to BetsyB - great job on the weight loss :thumbup:

[tinksmom 0]

I did the 3 month BCBS required supervision. My doctor didn't demand that I lose weight but he did want me to make lifestyle changes each month that would make me more successful post op. I was miffed at first but really appreciated both the psych eval, where I was encouraged to really think about this choice and talk it out with the counselor, and the nutritionist, who helped me understand the relationship between the band and my future dietary choices. Between them all I felt much more in control, and have come to appreciate BCBS' requirements.

[Becca29 0]

Hi!! I have the EXACT same situation going on! I have BCBS FEd and scince my bmi is less than 40 i have to do a 3 month supervised diet. I was pretty bummed ..but after reading on here that my DR. can start it from the initial weigh-in..( is this really true??) that makes thinks so much better. I have been waiting 2 weeks to hear from insurance and i just did today. So actually in 2 and a half months i could be having surgery.!!! I am so excited and thankful for all the help and support i get on these forums.

[perryjoyce 0]

My pre-op diet is minimal and I kind of wish it wasn't. I am way more excited than nervous, but of course there's a nervous element that grows a little each day and will probably keep me up with butterflies in my stomach the night before. Oh well, I can handle it! Bring it on!!

My boyfriend (of 9 years) is kind of the same way. He's a skinny little thing that can eat whatever he wants. He's sympathetic to my issues with food and can clearly see that I try and I try and yet I don't see much progress, so he's supportive, but I think he's trying to keep my expectations in check so he's yet to get really, really excited about it with me and is mostly silent on the issue unless I bring it up. Last night he finally told me that he really thinks this is the right decision for me and that he's impressed that I'm willing to commit so dramatically to altering how I can eat - forever. It was nice to finally hear that. I'm sure your hubby will come around, if not before, then definitely after when the results start to show!

I've never weighed less than the BF but I will! Oh yes, I will!!

[pearlgirl 0]

I was in the same boat as you. I was going to self pay but then was told that my insurance covered it if I did the 3 months of nutritionist/physicain supervised weight loss program. I was so discourged because my friend had self paid and she had hers 2 weeks after she decided. Then on top of the 3 months you have to await approval and then wait for your surgery to be scheduled. I wanted to just bite the bullet but luckily someone talked me into waiting. I am so glad they did. Because now, my WLS is scheduled May 24th and it is 100% covered. The weighting was worth it. Good luck in your process. I promise it will fly by.

[2beskinny 4]

Yes, you do sound like me! I'm sure you're glad you waited and now May 24 will be here a a flash. Congrats to you. I'm also glad I'm waiting. The "immediate gratification" thing is everywhere - even is this field It's a smart decision on our part. Not sure about you, but somehow if insurance companies say "yes" it adds more validation that I'm making the right choice!

[Leslie_RN 0]

Hello! I have BCBS of Ill and they covered 100% of my surgery (banded April 30th 2010). The only thing I had to do was see my general doctor once a month for 3 months for a "doctor prescribed" diet......I have been with my doctor since 1998 and I am a nurse so we, um, "documented" at each visit that I was on a high Protein low fat diet and checked my weight and BP at each visit....cost me $15 a month. Then I saw a dietician and had a psych eval (luckily from the SAME person who happend to be both) during one visit....she also is a bandster! That is all I had to do. The surgeon wrote a "Letter of Necessity" and turned it in with all of the information sent over from the doctors and we heard back within 2 weeks that I was covered!

Give it a try! You will be so happy when they tell you that it is covered at 100%.....hopefully! BTW my BMI was a 36-40 fluctuating and I had NO other co-morbities (diabetes, hypertension, etc.....)!

Good Luck!

Warmly,

Leslie

[2beskinny 4]

My pre-op diet is minimal and I kind of wish it wasn't. I am way more excited than nervous, but of course there's a nervous element that grows a little each day and will probably keep me up with butterflies in my stomach the night before. Oh well, I can handle it! Bring it on!!

My boyfriend (of 9 years) is kind of the same way. He's a skinny little thing that can eat whatever he wants. He's sympathetic to my issues with food and can clearly see that I try and I try and yet I don't see much progress, so he's supportive, but I think he's trying to keep my expectations in check so he's yet to get really, really excited about it with me and is mostly silent on the issue unless I bring it up. Last night he finally told me that he really thinks this is the right decision for me and that he's impressed that I'm willing to commit so dramatically to altering how I can eat - forever. It was nice to finally hear that. I'm sure your hubby will come around, if not before, then definitely after when the results start to show!

I've never weighed less than the BF but I will! Oh yes, I will!!

Sounds like your BF is a great guy. What a nice thing for him to say. My hubby is also quiet about it and we only talk about it when I bring it up. Part of that is my fault, I guess. I have trained him well..haha. He knows how sensitive I am about my weight and knows what a personal struggle it is for me. I'll admit it has been nice to "bring him in" to this whole thing because my weight battle has always been so internal with me. Not that externally it was being hidden, ha! It has been nice to have conversations with him without me getting irritated at his well-meaning advice, as before. He just wants me to be happy. You know, "when Mama happy...everybody happy!" That is sooooooo true when you live with a husband and 3 teenage boys

[2beskinny 4]

Hi!! I have the EXACT same situation going on! I have BCBS FEd and scince my bmi is less than 40 i have to do a 3 month supervised diet. I was pretty bummed ..but after reading on here that my DR. can start it from the initial weigh-in..( is this really true??) that makes thinks so much better. I have been waiting 2 weeks to hear from insurance and i just did today. So actually in 2 and a half months i could be having surgery.!!! I am so excited and thankful for all the help and support i get on these forums.

Yes, we are in the same boat My doc's office said same thing...they can count my initial consult as 1st visit. My visit yesterday was #2 and I go back 1st part of June for #3...that should be it. I questioned the logic as that's really only 60 days - not 90... She said they want 3 appointments and that's fine. I called bsbc to verify - the girl I've been working with has been so....great - she is also waiting to be banded! She confirmed same thing...3 doctor appointments with documentation of all the right things. When you said you heard from your insurance - did you mean you got approved? I'm happy with how quick my insurance got back to me at least. From when we submitted the 1st time to the 1st "answer" it was less than 48 hours. I'm hoping that when we re-submit in June it will be as quick - and of course, be a positive result. Then I could schedule as soon as 3-4 weeks after that. I've already had the psych eval and I had to do a gi scope. I had a little stricture in my esophogus that they used a balloon to expand. Nice not getting food stuck anymore. When I read about the painful stuck feeling that bandsters can get, I can totally relate because that would happen to me without the band. My doc just wanted to make sure there wasn't anything else going on and luckily there wasn't I think I actually may wait till mid-July to do it, however. I have 2 things going one with friends/family that are overnighters. I don't really want to be on a liquid pre-op diet at that time. Not because I want to pig out, it's that I'm not ready to tell anyone about this other than hubby and sister (my bff). I just don't want the attention to my diet. Hard for me - I've always been so internal about my weight.