Texas Teachers Please Report on BC/BS TRS Activecare

[Poodles 0]

Would like to know the following things from TX teachers stuck with the TRS Activecare from BC/BS:

1. How long did it take to get approval? If not approved how long have you been working to get approved?

2. Did they require a psyche eval? Nutritionist consult? sleep Study?

3. How many months supervised weight loss did you have before approval?

4. Did you have to call them constantly?

5. Were you denied the first time? Did you have to appeal?

6. Any recommendations for people trying to get approved?

7. What plan are you on (1, 2, or 3) and what was your total out of pocket?

Thank you for your input! This will help greatly! Know there are a lot of teachers out there trying to get approved and a little hope will help!

Here are my answers:

1. How long did it take to get approval? If not approved how long have you been working to get approved? Not approved. Working on it since Oct '05

2. Did they require a psyche eval? Yes Nutritionist consult? Yes Sleep Study? Yes

3. How many months supervised weight loss did you have before approval? They want 12, submitted with 6 but not approved yet.

4. Did you have to call them constantly?

5. Were you denied the first time? Did you have to appeal?

6. Any recommendations for people trying to get approved?

7. What plan are you on (1, 2, or 3) and what was your total out of pocket? Activecare 2, about $910.00 out of pocket so far.

[Mvpo8961 1]

:clap2: Poodles sorry I don't have your insurance or any info on it. I just wanted to let you know I'm rooting for you. Hope things go smoothly and quickly. M

[picardy3 0]

1. How long did it take to get approval? First consult in Dec. 05, everything submitted in Jan/Feb 06, verbal confirmation Mar 2, still waiting on official letter If not approved how long have you been working to get approved?

2. Did they require a psyche eval? yes Nutritionist consult? yes sleep Study? no

3. How many months supervised weight loss did you have before approval?

I see my doctor every three months for blood work and follow up due to diabetes and high blood pressure. I have been on a recommended diet from CDE since Mar. 04 and saw a personal trainer for 8 months in 05

4. Did you have to call them constantly? called once a week once I found out my information was submitted

5. Were you denied the first time? They did tell me on my second phone call that they were denying since I did not have my psych eval, but I had done that and resubmitted the info Did you have to appeal?

6. Any recommendations for people trying to get approved? Call, Call, Call and be extremely sweet, polite, etc. Be the sqeaky wheel

7. What plan are you on (1, 2, or 3) and what was your total out of pocket? I'm on plan 2 and have spent about $300 or so as of now.

I've just been lucky so far with my approval process since so many of the things that they were asking for I have already been doing for the past two years due to the Diabetes diagnosis in 04 and the high blood pressure issues. If I had not already been seeing the doctor for the following issues and had not seen a personal trainer whose notes I had included in my medical file, I would most likely still be on the six month supervised diet and waiting for approval.

Audra

[dolphin_dreams 0]

1. How long did it take to get approval?

Here is a timeline of how things went for me.

July 28- Met with surgeon,

August 22-received a letter requesting a psych evauation which I had already completed on Aug. 9th. I'm not sure what was up with that as my Doctor's office confirmed that BCBS had received a copy. The letter stated that "a thorough review would be completed upon receipt of the information."

October 4 - Saw a nutritionist and the doctor set a date for surgery.

October 5- I received a call from Doctor's office that I had been approved. I also got a letter from the insurace company the following week confirming this.

2. Did they require a psyche eval? yes Nutritionist consult? yes sleep Study? no I did not have to do a sleep test since I had already been through two. I was diagnosed with sleep apnea in November 2004.

3. How many months supervised weight loss did you have before approval?

I had over two years from my OBGYN

4. Did you have to call them constantly? No, I never called them

5. Were you denied the first time? I was approved the first time

6. Any recommendations for people trying to get approved? I've heard from others that politely calling once a week is helpful.

7. What plan are you on (1, 2, or 3) and what was your total out of pocket? I'm TRS plan 2. I was banded on November 8, 2005. My total cost including nutritionist, psych copay, surgeon, hospital, anesthesiologist etc.. has been about $2500.

Good Luck and please keep us posted on how things go.

Kendra

[lianna 3]

Hmmm, teach 6th grade, but........I ended up self pay due to an exclusion..(south texas health co-op) but then again my insurance sucks. We end up buying drugs and stuff in Mexico because it is cheaper than co-pay. I live on the border...

[Poodles 0]

New Answers:

1. How long did it take to get approval? 6 months. If not approved how long have you been working to get approved? Approved. March 20, 2006

2. Did they require a psyche eval? Yes Nutritionist consult? Yes Sleep Study? Yes

3. How many months supervised weight loss did you have before approval? 6 .

4. Did you have to call them constantly? Called every day after submitted, but just to check.

5. Were you denied the first time? No Did you have to appeal? No

6. Any recommendations for people trying to get approved? Write a good letter requesting approval with detailed info on illnesses and family history. Get Doctors to write letters for you. I had three doctors letters.

7. What plan are you on (1, 2, or 3) and what was your total out of pocket? Activecare 2, about $910.00 out of pocket so far.

[affy 0]

Hello-

I am a teacher in Beaumont. I was told that BCBS ActiveCare would not cover the surgery. I am on Level 2. I am happily surprised to see that you were approved. Can you help me out a little here?

a) Did your doctor send any special letters/paperwork to the insurance company?

What department at BCBS did you contact?

c) Do you think your choice of doctor had any impact on BCBS approving you?

d) Can you send me an outline of the letter you sent in?....without any personal info, of course.

Thanks for any advice you can lend.

New Answers:

1. How long did it take to get approval? 6 months. If not approved how long have you been working to get approved? Approved. March 20, 2006

2. Did they require a psyche eval? Yes Nutritionist consult? Yes sleep Study? Yes

3. How many months supervised weight loss did you have before approval? 6 .

4. Did you have to call them constantly? Called every day after submitted, but just to check.

5. Were you denied the first time? No Did you have to appeal? No

6. Any recommendations for people trying to get approved? Write a good letter requesting approval with detailed info on illnesses and family history. Get Doctors to write letters for you. I had three doctors letters.

7. What plan are you on (1, 2, or 3) and what was your total out of pocket? Activecare 2, about $910.00 out of pocket so far.

[Poodles 0]

I worked with lapbandsolutions that handled all the paperwork. They had me do a sleep study and stress test, and psyche eval before they sent the paperwork in. I just called customer service to check status. Don't think my choice of doctor mattered... think the fact I am falling apart helped.

Here is my MODIFIED letter:

March 1, 2006

Dear Sir or Madam,

This letter is to request your approval for Lab Band surgery.

I am a XX year old morbidly obese female who is X-X’ tall and weigh XXX lbs., giving me a body mass index of XX. With a BMI of 40 or greater, I may be classified as being very severely obese. With my abnormally high BMI, I am at an increased risk of death at my present weight. This is the reason that I have repeatedly been denied life insurance.

I am having significant adverse symptoms from my obesity. I have difficulty standing for long periods of time, I have back pain causing difficulty performing my daily activities, and in participating with my family in recreational activities. My feet hurt constantly, and this effects my work. I have hypertension and insulin resistance which further inhibits my weight loss efforts. These things would all go away, or be greatly alleviated with weight loss.

My family history is a concern for me as well. My paternal grandparents both died at an early age from heart problems and stroke, my father died at 58 from a heart attack (a few years after a triple bypass), and two years later my mother died, at 58, from a massive heart attack. Her first and last. Both of my parents suffered from adult onset diabetes and high blood pressure. Weight loss surgery seems to be the only way for me to alleviate my health problems and avoid these issues.

This is not a decision that I take lightly. I have made many attempts to lose weight on my own and this has gone on all my life. I was put on medications by my doctor to help lose weight. (A previous OBGYN put me on Phen-Phen before it was taken off of the market.) I have taken over the counter products and various Vitamin supplements. I would lose some weight then gain it all back, and more. I have tried many different nutritional and exercise programs. I have tried Opti-fast, Fad Diets (grapefruit diet, cabbage diet, etc), Microbiotic diet, Slim-fast, Richard Simmons, Susan powder, Thin for good, 6 week body makeover, and Atkins. I have literally spent thousands on weight loss products. I do low impact aerobics, yoga, swim, and walk as often as my back and feet pain allow. Nothing has helped long term.

I have stayed on my low carb diet for over three years now, and after some initial weight loss, my weight will not go down, and has slowly started to go back up. my Dr. has recommended the lap band procedure for me and would be happy to speak with you if you need confirmation of any of the above.

My PCP,, recently put me on a low calorie ADA (low carb) diet under 1000 calories, which is hard to maintain for me. I have sincerely tried to adapt to this diet, with limited success, because I get hungry. Dr. X has also recommended the lap band procedure to help with my medical problems associated with obesity. His letter should be in my file.

After my chest pain scare in 2002, I have tried to improve my lifestyle and lose weight. I watch my carbs, sodium, and calories all in an effort to avoid further hospitalizations and/or heart complications. Even though I try, I still have issues with maintaining blood pressure control, and have switched blood pressure medicines several times since 1998.

As you can see, I have spent all my adult life trying to lose weight. But, I need help. The lap band is an FDA approved form of weight loss surgery. (ICD9 Code 43843 CPT Code 43770) It is the least invasive and has no mal-absorption issues. The required diet is very similar to the Protein rich diet I have followed for years, but with the added benefit of hunger management. Therefore, I feel that this would be a very effective tool for me.

Obesity has been shown to directly increase health care costs. As my insurer, I am sure you can see the various visits to the doctors office for blood pressure, PCOS, depression, backpain, and the hosipital stay and cardiologist visits for chest pain. The medicine alone costs both of us. These costs will far outweigh the cost of the lap band surgery that I am asking you to approve for me.

As you can see I have exhausted all the traditional ways to lose weight. The lap band is an approved and proven means to permanently lose weight. Please approve this surgery for me. Thank you.

[picardy3 0]

Hello-

I am a teacher in Beaumont. I was told that BCBS ActiveCare would not cover the surgery. I am on Level 2. I am happily surprised to see that you were approved. Can you help me out a little here?

a) Did your doctor send any special letters/paperwork to the insurance company?

What department at BCBS did you contact?

c) Do you think your choice of doctor had any impact on BCBS approving you?

d) Can you send me an outline of the letter you sent in?....without any personal info, of course.

Thanks for any advice you can lend.

affy,

I'm also a BCBS Activecare level 2.

To be honest, I have no idea what letters or paperwork my surgeon sent in. I went to his seminar and was given a "cheat sheet" of what they would be asking for.

Here is what the sheet says:

Blue Cross Blue Shield of Texas, TRS and Federal policy requirements.

(Taken directly from the handout I was given at the information seminar)

1. BMI greater than 40

2. BMI greater than 35 with two of the following co-morbidities:

hypertension

Dyslipdemia - Lipid Panel

Type 2 Diabetes

Coronary heart disease

sleep apnea

3. A documented 5 year history of morbid obesity BMI greater than 40

4. A documented failure of continuous months of compliance with medically supervised non-surgical methods of weight reduction and must occur under MD, DO, or nurse practioner with the previous 24 month period prior to the request.

* Medifast or Optifast

* Behavior modifications or behavioral health interventions

*Supervised increase in activity

*Pharmacologic therapy

*Mantenance support to continue to encourage nutrition choices to reduce health risk factors

5. Evaluation by an independent, appropriately licensed professional counselor, psychologist, or psychiatrist who is unaffiliated with the surgical program. The evaluation must document the following:

*the absence of significant psychopathology that would hinder the ability of an idividual to understand the procedure and comply with medical/surgical recommendations

*Evaluation of psychological co-morbidities that contribute to weight mismanagement, and/or eating disorders

*Documentation of willingness to comply with preoperative and postoperative treatment plans.

6. Growth has been completed or 18 years of age

7. Mentally handicapped patients who are unable to understand the rule

8. Patients with Prader-Willi Syndrome

9. Portal Hypertension

10. Patients over 65 because weight loss is effective.

Gastric Bypass can be oper or Laprascopic

Adjustable gastric banding may be eligible for coverage

I'm sending you a PM with a bit of my personal information to see if any of it will help you. I'd rather not post all of that here as my post is beginning to get quite long.

Audra

[ashagirl 0]

1. How long did it take to get approval? 3 1/2 months (first appointment 1/23) approved 5/17 (banded 5/31) If not approved how long have you been working to get approved?

2. Did they require a psyche eval? Yes Nutritionist consult? Not that I know of...my surgeon's insurance coordinator handled everything Sleep Study? No

3. How many months supervised weight loss did you have before approval? I had years of documented doctor supervised weightloss from my primary physician...including things like xenical, Atkins, etc. All pieced together, I probably had 2-3 years as indicated in my official medical records. Of course, I've done nutrisystem, etc on my own.

4. Did you have to call them constantly? I don't think I had to, but the surgeon's insurance coordinator told me when to start calling, and I did...almost daily.

5. Were you denied the first time? Yes, they kicked it back for a psych evaluation, but the psychologist that my surgeon referred me to was also very experienced in this and fast and thorough with his paperwork submission. I think the kickback for the psych evaluation only cost us 2 weeks time, and the insurance coordinator told me not to worry that it was routine. Did you have to appeal?

6. Any recommendations for people trying to get approved? Go to a surgeon and office experienced in this process. Also, make sure your primary care physician and office will work with the surgeon.

7. What plan are you on (1, 2, or 3) and what was your total out of pocket? TRS Active Care 2...my TOTAl out of pocket....was $2,500...all paid 5/30....banded 5/31

[Poodles 0]

Just wanted to update my out of pocket. Including copays/myocel/etc this is what I have come up with... so far.

7. What plan are you on (1, 2, or 3) and what was your total out of pocket? Activecare 2, about $3485.00 out of pocket so far.

__________________

[Guest beaglemom]

I have TRS ActiveCare 2. The most expensive.

I'm thinking about lap band surgery. Who do people recommend? Where should I start?

My whole medical team seems to think bariatric surgery is a good idea. I know of two people who like it, but both are still in the process of losing. I know a third who is a successful "complete" patient -- don't remember what you guys call it.

My whole medical team includes: sleep doctor, endocronologist, and the nurse practioner at my cardiologist office. I haven't asked this primary care physician.

If possible I want to do it without disrupting my students and guess what I decided to teach summer school this year so not sure when I could do it.

[Poodles 0]

If you live near Richardson go to www.lapbandsolutions.com.

Where do you live? That would give us a good start on who to recommend for you.

And if you have a week off in between summer school and the start of school, you could get away with that!!!

[TexasTerry 0]

I am a Texas Teacher, but I opted to stay under my husbands insurance - it was actually cheaper for me at the time. I have a teacher friend that checked on having bypass done. Her doc told her that to qualify under the plan that she had to do a year of supervised Optifast and that NO doc in the area was doing it, so might as well kiss it goodby - she would not get approval. I'm going self-pay. My husbands insurance which is also BC/BS of Texas, but through the city, not school district, won't even talk to anyone about anything Obesity related. WHEN WILL THESE PEOPLE GET IT!

Terry

[Guest beaglemom]

If you live near Richardson go to www.lapbandsolutions.com.

Where do you live? That would give us a good start on who to recommend for you.

And if you have a week off in between summer school and the start of school, you could get away with that!!!

I live in Farmers Branch, work for Dallas ISD.

I did go to that site, and the parts that scare me the most is the total cost, even if covered, the two weeks of liquid diet and the fact that I use food to solve two problems, stress and loniliness.