BlueCross BlueShield SUCKS

[Mrs Husker 3]

When I talked to my insurance company, they informed me that LB would be covered. They even sent me a new book outlining my benefits. In the book it states under Noncovered Services:

Tretment and monitoring for obesity or for weight reduction,

regardless of diagnosis, excluding surgical operations.

I wanted to make sure that I understood that statement, so I called again. The person I was talking to said that they would not cover anything other than surgery. I asked again just to make sure that I understood her correctly "So Lap-band surgery is covered?" She said, "Yes".

Well, today I got a letter in the mail that states:

Benefits are not available for those services which have been

determined to be not medically necessary per physician review.

Therefore, no benefits are available for laparoscopic bypass surgery

(LAP band), as this has been determined to be not medically

necessary, as it does not meet medical policy criteria, as there is no

documentation of two years of medical management.:girl_hug:

So now I have to start the appeal process. I just find this very depressing. Does this mean that I have to pay out-of-pocket for "two years of medical management" because they will not cover that?

I just went and and got on the scale, I'm 224 lbs, I am 5'1", that puts my BMI at 42.32, I have sleep apena and joint pain. I realize that I don't have a lot of medical problems YET, but I was hoping to get it under control before I did. But even with the few problems that I have, my doctor, not a bunch of people who have never even spoken to me, beleives that the surgery IS medically necessary. Dam it, I just don't want to wait two more years. I'm even quiting smoking this Saturday, June 10. Not only will my surgon not do the LB is you smoke, I decided that if I plan on getting healthier, I need to do everything to get healthier.

I will have to call my doctor tomorrow and see what they have to say.

Thanks for letting me vent, I know some, if not most of you will understand.:think

[JulieLu 0]

Of course they won't cover your lapband surgery. However, they would be more than happy to pay for multiple sleep studies, diabetes medication, a CPAP machine, gout medication, high blood pressure medication, cholesterol medication, MRI's to diagnose back pain due to excess weight and the list goes on...

I cannot understand why insurance companies will not help people who want to deal with their weight issues. It seems to me that it would be much more cost effective for them in the long run.

My surgery is in a week. I decided to go the self pay route because I was sure my insurance company would never approve me. They basically agreed that I was fat but with only one co-morbidity, I wasn't sick enough. Go figure.

Good luck to you on your journey. Thanks for letting me rant a little.

[freebekie 0]

JulieLu,

I had my surgery a few weeks ago bluecross/BS of Texas covered the surgery, work with your primary Dr to document the problems you are having now and any weight loss efforts you have tried in the past two years.

[GeezerSue 7]

...

So now I have to start the appeal process. I just find this very depressing. Does this mean that I have to pay out-of-pocket for "two years of medical management" because they will not cover that?

No, it means that you have not (yet) documented that you have already tried "two years of medical management" of your obesity/morbid obesity.

[cindyn 0]

Ilive in Maine and BC/BS will only cover it if it is deemed medically needed and you have other medical issues (high blood pressure, edema etc etc) and if you have documented proof that you have years of other diet trials that have failed. My Primary physician has tons of documentation. BC/BS does take a bit of proof but keep trying.

[Mrs Husker 3]

Thanks for your encourgement. I have an appt with my pcp this Friday at 9:30 to get the ball rolling.

One question, dose LA weight loss count? I did that in 05, lost about 30 lbs and then gained 40 back.

[cindyn 0]

I am not sure what programs count so much as whether or not you were successful. I have tried em all!! Plus I take meds for Blood pressure, have swelling in legs, aches and pains of a typical overweight person.

My thoughts are yes there are risks but staying this way is a risk as well.

[Tricia K. 0]

Thanks for your encourgement. I have an appt with my pcp this Friday at 9:30 to get the ball rolling.

One question, dose LA weight loss count? I did that in 05, lost about 30 lbs and then gained 40 back.

From my understanding (and I may be wrong), any attempt at weight loss, whether medically supervised or not, will be considered when applying for coverage. However, I think that your doctor has/had to be aware of it so that it's written in his/her charts.

[JMO 0]

Keep fighting!!!!! I had to have med records for the past 5 years. Make sure your Dr. records everything..... Even if you tried slim fast for one week and stoped record it... Just remember Keep fighting.... Good luck...

[cherg 2]

Wow, I had BC/BS of Texas and it exculded weight lose surgery so they wouldn't cover it no matter what. I finally went to cigna and they approved it but the doctor was out of network so I would have a balance then I had gotten magnacare from the hospital i work at and they approved it. After my surgery 2 weeks ago, I received a letter from cigna saying they didn't have enough documentation and they denied the claim and this was after they originally approved it and my surgery was completed. Thank got I got the second insurance threw my job or I would have really been in a bind. So I understand when it comes to all the insurance bull. I have no real medical problems either just joint pain and a long time of tring different methods to lose and was unnsuccesful.

I wish everyone good luck and I feel your pain with the insurance.

[CCDC74 2]

Just keep on fighting with BC/BS. I had to go through 4 appeals before I was approved,the Doctor said I was the first BC/BS that had approved the LB surgery. I call the insurance every day they were open...Just keep on them!

[officegirlblues 0]

I know what you mean about BCBS. I hate it but it is my only option. I'm not sure what state you are in but Alabama will not cover it, period.

Have you checked back with your doctor? From what I read, and I could be reading it wrong, it is not specifically saying that lap band is not covered at all.. it is saying that it is not covered for you because you haven't met the criteria. Check and make sure that your doctor had deemed it medically necessary. The statement received from my insurance was different than yours. If your doctor does not say it is medically necessary then you have no chance. And, in talking to several doctors and nurses in our area, once it is approved you will still have to meet certain criteria, like diet history, etc. When you go back, just make sure that the dr's office is using all the correct terminology and covering all the bases with BCBS.

Good Luck!

[FunnyDuddies 6]

I am curious. They stated Laproscopic Bypass (LapBand) but this is not a Laproscopic Bypass. It is Laproscopic Adjustable Gastric Banding. BIG difference!! Just make sure they approve you for the correct surgery! You don't want to work really hard at getting an approval for Lapband and then find out you are only approved for laproscopic Gastric Bypass.

Good luck!!!

[gordonfamily3 0]

I do the billing for our surgeon..BC/BS of NC says the band is investagortial and they want cover it. Go figure... My expereince w/ all the differnet BC/BS is they want a doctor supervised diet...our BC/BS requires a 5 year weight history (one weight per year for the last 5 years.) BC/BS has a healthy lifestyles section - check into that we encourage all our patients to sign up for it becuase it pays for a nutritionest so it's not out of pocket money for you. Good Luck and fight - don't take no for an answer!!!!

[pplqueen 0]

I have BC/BS and was approved in 1 hour. NO JOKE. I am having surgery June 21st. I think that it has alot to do with your doctors office. They had all of my paper work done. They already knew what I needed to send in.

I would stay on them. Find out who is handling your case with your insurance. Call them up and befriend them. It worked for me.