BCBS Federal denied pre approval

[nouveau-debut 0]

I am fuming! I did all my research prior to my testing and was told as long as it was medically necessary, they would approve the sleeve. Now I am being told it?s too new and considered investigative. I know other regions for BCBS Federal have covered the sleeve. I?ve talk to people on 2 different supports group, but I not necessarily in my state. I left a message with a rep to discuss but don?t know how far I will get. They will approve the bypass. I understand most sleeves are self pay, but I just think this is ridiculous!:cursing:

[lapfish 0]

Mine has also been disapproved for the same reasons that you stated. We need to get together and find out what states that are FEP Blue are covering it. I am in Colorado. I am at a stand still because I dont' want the Bypass. My PCP today said I should just go ahead and get the lapband but I don't want that! I have until the end of the year to get it done because my Cat cap has been met. I would have to pay nothing for the surgery right now.

[nouveau-debut 0]

I have been getting some help from the Obesity Help site. They told me to appeal. I played phone tag on Fri trying to find out who to contact and how to appeal but got the run around. I also found out that my Dr went ahead and submitted me for bypass for ins to approve. It might hurt my chances at appealing. I am going to start the phone calls again tommorow. Look at www.thediaryofafatwoman.com- it's a blog where a woman won her BCBS appeal for VSG. It took several months, but she won.

Stay in touch and I will let you know what I find out.

[lapfish 0]

Have you heard anything? I looked on that blog for diary of a fat woman. She has a wonderful blog full of info on BCBS appeals. I wish there was some way to contact her but there isn't. I don't see pix there either. I will use some of her first appeal letter to do mine. I just received a note back from our state and the insurance commission tells me I have to appeal through the plan administrator, whoever that is? I am on a rat race here! Talk to you soon.:cool:

[nouveau-debut 0]

Unfortunately I am still making several calls every day and not getting anywhere. They said they have 6 months to reply to an appeal which has to be a written letter to the Appeal Level 1 Dept. It's hard to do all this when you are at work and they are only open during my work hours.

[attitudefree 2]

I am so sorry your sleeve was declined. I wish you the best of luck in your appeal process. I know there have been a couple of people on this site who have appealed and won- you may want to start a new thread asking for appeal advice

[mountain_lover 3]

I am fuming! I did all my research prior to my testing and was told as long as it was medically necessary, they would approve the sleeve. Now I am being told it?s too new and considered investigative. I know other regions for BCBS Federal have covered the sleeve. I?ve talk to people on 2 different supports group, but I not necessarily in my state. I left a message with a rep to discuss but don?t know how far I will get. They will approve the bypass. I understand most sleeves are self pay, but I just think this is ridiculous!:laugh0:

Hello nouveau-debut,

After reading your thread on here, I decided to go back to where I posted on the Pre-Op forum and copy & paste a reply that I made to JSM to put on this Insurance and financing forum do to its content. Please read my thread titled, "PLEASE READ THIS IF YOU NEED TO APPEAL. (BCBS AND OTHER COMPANIES). I hope it will help someone.

Keep us posted and let us know how it is going for you. I have been working on mine for almost a year. They just submitted my information to Medicaid here in KY. yesterday, we should hear back from them in less than a week. When I first started, the sleeve was not an eligible procedure for an approval, but now in some cases they are approving the VSG procedure. You can send me a message to let me know if this helped in any way with your situation, Have a good day!!

[brittu 42]

Well my advice is to keep fighting and go for the appeal. The BCBS plan statement actually has to be administered uniformly across the country but some local companies doing the administration (like Regence here in Washington) are disregarding the benefit guidelines and denying it.

I had a slipped lapband and was told that VSG and band removal are both covered. VSG is supposed to have been allowed as a gastric restrictive procedure by Fed BCBS as of January 1st 2008. (My lap band was originally covered by my insurance because I met the >35BMI + 2 comorbidity requirements.) Even after both the doctor and I were told the revision would be covered, the local Regence office sent a denial letter. They appear to know nothing about weightloss surgery or the lap band, much less the VSG -- they were so far in the weeds they actually denied removing the band and claimed they couldn't remove it because my BMI wasn't high enough any more (huh?). And they denied the VSG revision under the investigational claim. They even denied letting me have it unfilled so we could get the pain and vomiting under control. They said fills are only covered when your BMI is over 35 too. That's going to be news to lap band patients everywhere - don't bother contuing to use your band once you lose some of your weight. That was such a stupid thing for them to do all I could do was laugh about it. They backed off that pretty quick, after hassling me about it they suddently stopped mentioning it and just paid the claim.

I ended up appealing. For the first round of my appeal I wrote my own letter and won the band removal portion only but they denied the VSG again. They dropped the investigational reason and their denial to being because I don't qualify for weightloss surgery with a <35 BMI. Since I did qualify for the original lap band surgery that's kind of dumb. The standard of care with revisions is not to treat the revision as if you're starting over pre-WLS so it makes no sense. You don't give someone a knee replacement and then when it breaks and the doctor needs to replace it with a different type of artificial knee that the patient is out of luck - you only get one shot a knee replacement. My BMI is back up to 33 so they won't have to wait long until I qualify again .

Although the surgeon and I wanted to do the removal and revison in a single procedure, I went ahead and just had the lap band out in October. The insurance company gave me four weeks to have it out from the date of their appeal decision so I just needed to get it done. And I was miserable. I can't believe anyone would force me to keep a slipped lap band in for over 7 months - that's crazy. It's great not to be in so much pain. But it's scary to no longer have any kind of restriction.

I went ahead and hired Walter and Kelley Lindstrom to handle the appeal from here. Well worth the money just to have someone fighting for me after going it alone for so many months. We'll see what happens, I should know what the Office of Personnel Managment in D.C. wants to do next in a couple of weeks. I'm going to take it all the way to the end to make sure this gets their attention - that some state administrators are making up their own rules that go against the benefit statement.

I posted the letter and addendum I used for my first appeal in case it's useful to anyone else. All I know is that it did seem to get them off the investigational part of the denial.

Best of luck!

Britt

vsgappeal: Appeal Letter

[gatorman 3]

I am in Florida and BCBS of Florida won't cover any WLS, or at least my plan won't. I was told to appeal and that I could probably get them to pay for By-pass or LB but now that I am 100% leaning toward the Sleeve I found out they won't pay for it at all. Honestly, since I had already figured I was going to have to self-pay I am not even going to try and fight it. I don't want to wait any longer to get my new life started. I have been overweight too long and I don't want to go through another 6 months of "Physician Approved" dieting. I've tried everything, adipex, Weight Watchers, Atkins, Grapefruit. . .always to yo-yo back up.

Good luck and I hope you have won your appeal.

[MINI-Me 196]

I've heard some people have the surgeon submit for a 2 part DS - with the sleeve being the first stage. They just never went back to have the 2nd part done. Is your BMI high enough to qualify for DS?

[gatorman 3]

I've heard some people have the surgeon submit for a 2 part DS - with the sleeve being the first stage. They just never went back to have the 2nd part done. Is your BMI high enough to qualify for DS?

Possibly. My BMI is at 44 right now.

[MINI-Me 196]

Possibly. My BMI is at 44 right now.:blushing:

It might not hurt to try ... all they can say is no. Plus, if you can't get to goal with the sleeve (not that I think you won't), you always have part 2 pre-approved!

[maxcat 0]

http://verticalsleevetalk.com/insurance-financing/1451-bcbs-federal-denied-pre-approval.html She did get approved.

ObesityHelp.com - Insurance trouble

http://verticalsleevetalk.com/insurance-financing/3390-bcbs.html page down to Tiffykins and she has about 5 links on there that might help you.

When I first talked to my surgeon he said if I could not get approved for VSG what other one are we looking for to get approved, I said none. Its either the sleeve or nothing.

I will be in your shoes soon too but I have Keystone Health Plan East.

Good luck and let us know how it works

[ShellieB73 0]

I can so relate to the initial post here.....

I was banded in Feb 2008....did absolutely wonderful until November 2009. I had a slip that was discovered on a routine UGI. Looking back I did have some sypmtoms, but overall had lost 80 pounds and was maintaining without any difficulty.

I had my band removed in March of this year....after the roller coaster insurance battle. The technically can't deny removal of the band as it could potentially be life threatening (rare, but possible to have part of your stomach become necrotic). The refused to replace the band because I was no longer "morbidly obese". My surgeon was about as frustrated as I was!!!

Now....after gaining since November....I am pretty close to the BMI of 40.....frustrated, mad, depressed....blah blah blah!!!!

My dilemma now is that I live in Iowa and the sleeve is not commonly done here. My surgeon is doing them, but insurance coverage is spotty. Due to a job change, I am getting a Wellmark/BCBS product beginning May 1st....

Does anyone have any information about Wellmark in Iowa covering the sleeve any time soon? Honestly, I don't see why they don't....it would be much better from an insurance standpoint. No fills, no frequent appointments....it is a much better surgery, I believe.

thanks for letting me rant....

shellie

[dentonpl 0]

I just got my denial letter yesterday from Federal BC/BS. I am in Colorado (Parker). I am so disappointed. But I feel hopeful after reading all the successes posted here. I would appreciate copies of anyone appeal's letter. I just need a starting point. Brittu-I did printout your appeal-Thank You!

Lisa

dentonpl@aol.com