BCBS of TX.....HELP!!

January 22, 2006

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:

ReneBean · January 23, 2006

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!!

Poodles · January 23, 2006

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!

January 24, 2006

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

ReneBean · January 24, 2006

Yes!! My doc supervised history was from 8 yrs ago... Go for it!

Good Luck!

leatha_g · January 24, 2006

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!