Approval After Lap Band Surgery??

[stuntmonkey 2]

I have CareFirst BCBS (BluePreferred PPO, DC plan), and I have met all the requirements for my insurance. (I called back when I started this process, and my employer's plan does cover bariatric surgery, so no worries there.)

I am over 18.

I had a successful psychiatric evaluation for bariatric surgery.

I did a structured diet (WW) for six consecutive months, going at least once a month.

My BMI is over 35 and I have severe sleep apnea.

My submitted all my stuff to my surgeon's office, and they submitted it all to my insurance. Well, my surgeon's office called me back to today and left a message that my insurance plan doesn't do preapprovals for bariatric surgery, and the insurance company said that they will pay for my surgery after the fact.

The nurse isn't in tomorrow, and I will call her back on Monday morning for clarification, but now I am curious/worried about this. Is this a common occurrence? It seems weird that I have to have the surgery first before they will make the final decision on whether they will pay for it or not.

Any experiences you can share with this would be very, very appreciated! Thanks!

[Corrigan 75]

I had Medicare and CHP Blue cross, they both said they would let me know after surgery, whether or not they would cover

it (they did), but that makes for some anxious moments. So far, they've paid for everything, but every letter from Cedars-Sinai

makes my heart go pitty-pat.

[bromo 17]

I have medicare and was not really worried since I easily met the criteria. They approve after the fact, as corrigan said. Not a problem at all and only owed the doctor 72 cents more than we figured. lol

[Jess55 97]

I'm pretty sure my insurance said the same thing. And I was like WTF, but they ended up paying for it. I had to pay a copay of $250, so I was ecstatic (and I originally thought my copay for the surgery was $500, so I was even happier LOL)

[loretta\ Baconton Georgia 10]

YOu only have one comobidity? I would be concerned. With BCBSI and most others, you need two. Call and ask for a copy of their policy to make sure that you qualify. I would hate for you to get stuck with a fat bill.

[stuntmonkey 2]

Thanks for the replies, everyone.

I called CareFirst on Friday and went over each and every requirement with the representative on the phone.

They only require one comorbid condition when your BMI is over 35. I checked twice. Severe sleep apnea counts.

I am still frustrated because the rep I talked to said that "In her opinion, she saw no reason I should be denied coverage, but they will do a review of my file after the surgery to make the final decision." I just think that's nuts!

From everything I've read and from my long and detailed conversation with the insurance representative, it sounds like everything will be fine, but wow, this is nerve-wracking. I would really prefer a pre-surgery approval!

Here is a cut and paste of the official policy of my exact plan:

Surgical treatment of morbid obesity is considered to be a viable treatment option in patients who meet allof the following criteria:

Age: (criteria met -- I'm 33.)

• 18 years old or older and
  

Psychological examination: (done and submitted to my surgeon)

• complete a psychological examination to determine readiness and fitness for surgery and necessary postoperative lifestyle changes and
  

Structured diet program: (I did WW for 6 months. I went to at least one meeting a month and have the sign-in records and my payment records.)

• Maryland and D.C. plan members only: must complete a structured diet program in the 2-year period that immediately precedes the request for the surgery by participation in either:
  

- one structured diet program for 6 consecutive months or

- two structured, non-concurrent, diet programs for 3 consecutive months. (can include commonly available diet programs such as Weight Watchers® or Jenny Craig®) and

Weight requirement: (BMI is about 40 (depends on the day), plus I have severe sleep apnea)

• Maryland and D.C. plan members only: must meet eitherof the following criteria:
  - BMI of 40; or
  - BMI equal to or greater than 35, in combination with one or more of the following co-morbid conditions:
  hypertension;
  a cardiopulmonary condition;
  sleep apnea;
  diabetes mellitus; or
  any life threatening or serious medical condition that is weight induced