question for Bob from NJ !!

ihvbzs · February 3, 2004

Hi Bob, I saw in a post that you are from NJ and were turned down by your insurannce.........I was hoping i could ask you who your ins. is with ?? I have Horizon B/C & B/S of NJ. I have gone for my nutritution appointment, my phyc evaluation and my gastro app. today and the office will not sumit till all this is done so i am afraid i will go through all of this and be turned down. Any help is appreciated........THANKS

Alexandra · February 3, 2004

Hi there!

I'm not Bob but I'm also in NJ, and what's more, I'm an insurance broker. I can give you the good news that Horizon BCBS is indeed a band-friendly carrier! You're very lucky.

You will of course have to qualify as MO and your doctor will have to make the case that band sugery is medically necessary for you, but that's true with any carrier. I can't tell you if you'll qualify for sure, of course, but if you want me to guess I'd need more information.

But you're in great shape with Horizon BCBS. Go for it! :confused:

February 3, 2004

Hi Alexandra:

This is my first post here, though I've been lurking for about six months. Since you are an insurance broker, perhaps you can help me answer the same question as the first poster. Here's my background info:

I've been seeing the nutritionist since Sept. 2003; I had my psych. evaluation in Dec. 2003; PCP recommendations (he's the one who asked me to first consider WLS, I then chose the LapBand based on my findings); attended mandatory support group meetings (even though they were only for RNYers); consult with surgeon Jan. 22, 2004. During that consult, he scheduled me for endoscopy and a visit with my friendly neighborhood cadio/pulmonary specialist. Unfortunately (and I'm heartbroken because of it), he WOULD NOT schedule a surgery date.

All of the above Dr's. appointments are my surgeon's requirements. I got the impression that they do most of the leg work when it comes to the insurance cos.

I have BC/BS of Northeastern New York. I belong to the "205 Plus" plan, which DOES NOT REQUIRE REFERRALS??!?!?! However, when I called them just to make sure that they in fact covered lap bands, the woman said they did, with your PCP's referall? And she advised me to submit "everything" (meaning evidence?) when I was done with all testing.

Do you think my chances are good? Can I do anything else to promote a sucessful outcome? Any advise would be most appreciated.

I'm having a hard time since seeing my surgeon. Diet is NOT going well, and I've become VERY depressed. I was SOOOO looking forward to having a surgery date. I waited 9 months JUST to get in his OFFICE!

Staci

Alexandra · February 3, 2004

Hi Staci,

It sounds to me like you're well on your way to an approval. Your surgeon is doing everything right; he needs to see the test results before scheduling your surgery date. There's no point in scheduling it before he knows you're a good candidate, right?

The next step is for his office to gather all the material and test results and whatever else and submit it to the carrier with a request for precertification. That's what the phone jockey meant when she said "referral." In a non-gated plan (which is what you have) you don't need the PCP's referral but you ALWAYS will need a precertification from the carrier for surgery.

Of course, a letter from your PCP (if you have one) describing your history of obesity will always help, and probably should be included in the file submitted to the carrier. But that's not the same thing as needing a referral.

It's not usually until the file is submitted that a date for surgery is scheduled. That way the carrier has a deadline to meet. An approval (or denial) should come back within two weeks. There is probably a rule about the time frame in your state if you want to look at NY's dept. of insurance website.

Don't worry. I know that BCBS of NY has been more band-friendly of late, and if you were told the band is a covered procedure you're in very good shape.

GOOD LUCK and please keep us posted.

February 3, 2004

Thank you! Thank you! Thank you!

Alex, I know that there are no guarantees with ANYTHING ... especially something like this. But you've really made my day. Just reading the words made me feel better!

Thanks!

P.S. I want to say that as a lurker (who promisses to do more posting), I think that you are definately a bright spot on this Board. You keep everyone motivated, informed, and upbeat. Thanks for that. And another thing .... you are probably one of the MOST sucessful bansters, IMHO, because I've NEVER heard you spout the usual post-op complaints. To someone struggling to get there, like myself, it is difficult and depressing to hear how someone "ONLY" lost 15 pounds last month .. or his having "SUCH A HARD TIME" getting in their calories. I know this is a battle I will fight all my life, and I'm ok with that. But to those of you that HAVE the tool: PLEASE PLEASE PLEASE never forget what a blessing it is. If you're having a hard day or "head hunger", just think back to the days BEFORE you had help! That's what I go through EVERY DAY ... without loosing a POUND!

OK ... that's enough preachy-bitterness for now. I'm happy happy happy happy! I have a chance! There IS light at the end of the tunnel!

Alexandra · February 3, 2004

Staci, thank you for the nice words! You made my day!!

I know this is a battle I will fight all my life, and I'm ok with that.

You know what? I think that's one of the ingredients for a successful bandster life. Banding is NOT a quick fix or a miracle cure, and those who think it is are the ones bound to be disappointed.

Frankly, I gave up on diets (and on being thin) a long, long time ago. My goal was and remains staying healthy. I was doing a pretty good job until my kids were born, and then my weight stabilized at a point some 50 lbs above what had been my heaviest weight before that. I'd be happy if I just could get that 50 lbs off, permanently. Heck, I'm happy now that 35 lbs has come off AND IS STAYING OFF. When I want to lose more I know it's within my power now in a way it has never been before. Thank you, Inamed!!

That's the measure of success that I use. That, and staying level-headed and sane about it all. :confused:

Mahoney · February 4, 2004

Hi Staci & ihvbzs,

It sounds like Alexandra has some good news for you. The most important thing is to have a carrier that is band friendly. I'm a complete rookie to all of the insurance stuff, but I learned that in my case at least, it was a lot easier to demonstrate medical necessity for WLS than it was prove that the lap-band is not experimental/investigational. I got denied by AmeriHealth last year because of that, and got denied again this year from Benefit Planners for essentially the same reason. Both would have approved me for the RNY gastric bypass. Because my insurance plan is self-funded, I had limited options to pursue it further. :confused:

The other thing that some of these insurance companies hit you on is a medically supervised diet with regular weigh-ins at your doctor for 6 months in the last 2 years, or even 2 6-month medically supervised diets. Alexandra - do you know if BC/BS requires this?

Best Wishes!

Bob

tangerine · February 4, 2004

Alexandra, you're doing great!

I thought I'd chime in here with a BCBS question too. I have BCBS of NJ PPO, do you know how they are with reconstructive surgery? I have horrible hip and back pain from my hanging skin and my belly button gets infected all of the time. Some insurance carriers won't cover these things even when medically necessary, so I'm wondering how BCBS is with it. No way will I be able to save enough money for a Tummy Tuck in the near future and I'm going to need one fairly soon.

Thanks!

Alexandra · February 4, 2004

Hi Alexis, you bouncing bunny!

I'd be happy to help but first I need to know if your plan is a small-group plan. Does your employer have fewer than 50 employees? If so it will be relatively easy to find out what's covered under your plan. Let me know, OK?

ihvbzs · February 5, 2004

Alexandra...you are sooooooo very helpful!! Thanks so much for the info !! I do have sleep apenia and arthritis but I just made the right BMI by a couple of pounds so I was worried. You are so right about feeling good..........it's not all about the right size, it's about being able to be you again !! All I want is to be able to climb stairs again easily, swinging a golf club again and fit into the rollercoaster w/ the kids this summer. I am at a time in my life that I am in search of a weight loss tool and I pray this is the one !! Thanks again !

Alexandra · February 5, 2004

Originally posted by Mahoney
The other thing that some of these insurance companies hit you on is a medically supervised diet with regular weigh-ins at your doctor for 6 months in the last 2 years, or even 2 6-month medically supervised diets. Alexandra - do you know if BC/BS requires this?

Sorry I didn't see this question earlier. I'm sorry, I don't know precisely what BCBS's criteria are for qualifying patients for WLS. Perhaps someone with that carrier can chime in?