BC/BS Alabama

[kaydefowlr 0]

I was approved for the Lap RNY Gastric By-Pass on June 18, but my surgeon (Dr. Foreman of Al. Surgical Associates Bariatric Program) insisted I lose 30 lbs prior to surgery. So this is where I'm presently at - in the middle of trying to lose 30 lbs.

At the time of my consult (Aug 2009) I weighed 371 lbs and was told I had a pre-exisitng condition that would not lift until May 26th of 2010. So I began my BC/BS required 7 office visits in 180 days prior to pre-approval submission for surgery. Since Aug 09 I had gained up to 393. So not only do I have to lose down from that to 371 I then have to lose 30lbs before surgery. :-(

When I met with Dr. Foreman I clearly remember him recommending the VSG w/duodenal switch due to my Super Morbid Obesity - I was uninformed at that time about VSG and therefore when I was put on the spot to choose what surgery I wanted I chose the RNY.

Thus why his office insurance rep submitted me for RNY and my subsequent approval. Here's the rub, I don't want RNY - all the research I have found clearly shows that the VSG assists the Super Morbidly Obese at losing weight all the way to the healthy goal and keeping the weight off longer if not for life!

I called BC/BS today and inquired as to what I would need to do to possibly appeal to Blue Cross for a conditional approval - and I was told to write a letter including all relevant information pertinent to me to the Medical Review Board. I am going to start this first thing tomorrow.

Anyone on here know of anyone with BC/BS AL who was approved for the VSG???? Did they have to appeal to the board???

Thanks in advance!

Edited June 29, 2010 by kaydefowlr

[ksaucy 0]

I sure would like to know as well! I have BC/BS of AL too. I'm in the middle of compiling my 6 month diet information and all documentation I can think of to try to get this procedure approved. It is currently listed as investigational under their policies so I'm thinking it's going to be quite the fight.

I would love to hear other BC/BS AL stories too!

[mila1013 0]

hi,

so this seems like a 2 part question. Just because you got RNY approval does not mean you have to have it and you are in a great spot, they have approved you for wls, not it is stricly a case of the kind you want. First I can't see how you would be approved for a surgery that was not pre authorized, in other words, your surgeon would ask for the sleeve (or DS, with your bmi it would be easier to get DS approved as there are more DS articles out there for you to bombard bcbs with) while i know the sleeve is part one of DS, bcbs are morons, you have to know your apponent and how to play that stupid game they put you through, anyway,the question is not about your insuance in that state, it is your specific plan not all insurance plans in that state are the same. So asking question about bcbs in a certain state really is futile. get a copy of your subscriber agreement and read it and know it, that is your legal contract between you and bcbs, not what anyone else has or says. good luck with navigating through insurance, they intentionally make it difficult. I have bcbs (not your state) and they have denied my perauthorizations 100% of the time, I have had to appeal every time since procedure I have had -and that would be 7 by the way, currently I am waiting for me sleeve denial, so predictable of bcbs.....

[Kelkie 0]

I have BCBS North Dakota. They denied me first because of it being investigational. My surgeon filed and appeal, and I wrote a very detailed letter to go with it, saying why I thought it was the best procedure for me, and therefore medically necessary. BCBS reviewed the appeal, and then sent it, on their own, to an external reviewer. Three weeks later I was approved, three weeks after that I was sleeved. I have read of a couple of people on here that had basically the same experience with BCBS Il. Other than the waiting it was a relatively painless process. Good luck, and don't give up on what you want. It's not impossible.