Jump to content
×
Are you looking for the BariatricPal Store? Go now!

BCBS of TX.....HELP!!


Guest Buddy Lee

Recommended Posts

Guest Buddy Lee

So I finally decide that getting banded is the best possible thing for me now. I have been diagnosed with Apnea, I am well in the severe range on my BMI. However I have BCBS of TX. They have strong stipulations on the approval process. I have the 5 year history of being over weight. But they also want 12 months of a documented lo-cal diet and exercise program initiated by my PCP.

My question I guess would be does anyone know of a work around for this or am I going to have to wait another 12 months to get banded!?

At this point I am so fustrated, I have been denied already once due to "Not having enough medical info". I am seriously considering quiting my job of 6 years and paying high insurance prices and not getting anything out of it, just to apply for Medicare.

In the last 6 years I have paid well or $70,000 in insurace and seriously have used it maybe 10 times. Why is this so difficult?????

Is there any hope at all for a work around. There seems to be some people on here with knowledge of working the system, just thought I would put this out there to see what I can do to fight this.

Buddy Lee:help:

Share this post


Link to post
Share on other sites

Sorry Buddy - BCBS is tough in any state - but TX seems to be particularly difficult. Did they say they needed more info? Or did they specify that you don't have enough diet history?

It could be that your doc didn't submit some particular record they are looking for, in which case you just have to get it and try again.

If they denied you for lack of diet history, you can appeal - but be prepared for it to take a long time. It took from September to LAST WEEK to get my insurance approval - I had to appeal and then appeal to the state of California insurance board for an independent medical review.

**Also - if your BMI is over 50 - you have a real fight on your hands. That is why I was denied - BCBS policy says anything over 50 requires one of the other surgical procedures (Bypass or Duodenal Switch).

Feel free to e-mail me with your e-mail address if you want to see my appeal letters.

Good Luck!!

Share this post


Link to post
Share on other sites

LapBandSolutions submitted my request with 2 months doctor supervised weight loss. They requested more. LapBandSolutions said that we need to wait until 6 months before we submit again. They have said that they have seen people approved with the six months, as long as they have co-morbidities, and a persuasive note from their PCP. I will be able to resubmit on March 1st. Will let you know if I get approved with 6 months or not.

How many months under a doctors care do you have? I would recommend starting as soon as possible... and don't miss a month!

Share this post


Link to post
Share on other sites
Guest Buddy Lee

Well after thinking about it more, I have been going to the same Dr. since I was about 12. I know in high school that I was referred to a neutritionist to be put on a diet. That has been several years ago, but the paper work does not state that the diet has to be recent. I think I might be able to get this handled. I have put a call in to my physican for an appointment to talk more about this. I just gotta keep my fingers crossed that they have my records from back then.

As for the BMI over 50. Last time I tried I did not have the tests and paperwork to back up my claim for approval. I went to a Dr. that tried to get me approved straight with no history. I am now working with Dr. Provost at UT southwestern Medical Center. He told me that a band on me would be just fine. I hope that everything works out with my regular physican so that we can get this paper work sent off for approval.

Buddy Lee

Share this post


Link to post
Share on other sites

Do ask your doctor about backdating information in support of your hope to have weight loss surgery. My brother and sister in law had the same problem with BCBS, so they had to go back to their PCP and ask him to document each time they discussed their obesity and any attempts they had made to lose weight, either with success or without. They did have to wait about 8 mos, but the PCP was helpful in getting it moved along. To this date, my sis-in-law has won her appeal and been banded, my brother is still waiting for his appeal to be reviewed.

Good luck!

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Trending Products

  • Trending Topics

  • Recent Status Updates

    • Bashbee91

      Hey guys new to the process looking forward to this new life. 
      · 0 replies
      1. This update has no replies.
    • Bugg

      Hi everyone! I’m brand new here. I just went through all my pre-op requirements per my insurance company and now everything has been submitted and I’m just waiting for final approval and my surgery date. I’ve been doing research, watching YouTube videos, TikTok’s, ect.. trying to prepare my mind and what to expect so I’ll be ready for the surgery. I was so sure and so set and so ready and excited. However, now that I’ve done everything & it’s almost here, I am sooooooo scared! I know why I want it bc I’ve tried everything and I just don’t feel like I can lose weight by myself. I’m tired of being overweight my entire life. I’m miserable, but I keep psyching myself out afraid of GERD bc I know how that can be and I don’t want to have to get a bypass after already gaining the courage to even get VSG. I’m scared of complications like I’mgoing to regret doing it and be depressed that I didn’t just be more disciplined and try again to lose the weight on my own even sitting here typing this knowing in my mind i just can’t and don’t possess the discipline. I’m also afraid I won’t be able to handle the restrictions of the sleeve. What do I eat? I don’t know how to eat healthy really and don’t enjoy healthy food. I don’t know how to do this! I feel so defeated!Someone tell me they felt anything similar to this or am I not ready? I thought I was. I am so tired of being sick and tired and so tired of myself and so tired of being stuck and stuck in this body and somebody different on the outside from what I feel inside. I just want to ball up and cry.
      · 0 replies
      1. This update has no replies.
    • buildabetteranna

      over 20 lbs down since4 the pre surgery diet and surgery on the 14th
      · 1 reply
      1. Selina333

        Yay!! Congrats. I know how good that feels. 🤩

    • Jenopolis

      Had a sleeve in 2017, lost over 100 pounds. Had a DS surgery this year (2025) for more sustainable weight loss. 🤞
      · 0 replies
      1. This update has no replies.
    • buildabetteranna

      The 14th was my day. I am home and recovery is going pretty smooth. They even let me walk out of the hospital. Picture of me in recovery curtesy of my boyfriend lol. 

      · 3 replies
      1. DaisyChainOz

        Glad it went well!! Wishing you a speedy recovery and wonderful success!! 🤗

      2. buildabetteranna

        Thank you ❤️

      3. Selina333

        Neat you have a pic of this day! I was sooo happy to get my surgery. It was well worth it! And I'm not even near my goal. I had surgery Dec. 2!

  • Recent Topics

  • Hot Products

  • Sign Up For
    Our Newsletter

    Follow us for the latest news
    and special product offers!
  • Together, we have lost...
      lbs

    PatchAid Vitamin Patches

    ×