BCBS Aproval problems- Ayone with any type of BCBS please read

[warrior68 16]

I have excellus BCBS Blue Point 2 insurance here in NY, I have been denied again, stating that the sleeve is exploratory / investigational. I am going to appeal the denial, and was wondering if anyone that has any type of BCBS Insurance that was approved for the sleeve to please post here with which company you have, what state you live in, and when you were approved. My thinking is that if I can provide a list of BCBS entities that have covered the sleeve, Excellus BCBS Blue point 2 could hardly then state that it is experimental or Investigational.

I posted this in a couple different threads hoping to have as many people as possible see it, sorry for the over posts.

[Susanne 32]

Cross posting, never good - the admin may delete some of them and then people who replied there did so in vain.

Aside from that, I am with BCBS PPO Michigan. They started to support the sleeve November 1st (and my surgery was on the 2nd) for people with a BMI of 40+, they just changed their mind about it.

Maybe you can check with them and find out WHY they changed their mind? There must have been a reason why they switch now, so that could be a starting point.

What are your stats?

[KabinKitty 11]

BC/BS of Ohio just started covering the sleeve as of 11/18/10. My paperwork was recently resubmitted and I'm waiting for my approval.

The weight considerations are: 1.BMI of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid conditions.

I hope this helps!

[myrori 55]

I have BCBS of IL PPO and I was approved in August no problems. I do not know what their requirements are but my bmi was 41 with co morbilities.

[gotamakeachange 7]

I have BCBS PPO of MI, like Susanne said they began covering the sleeve 11/1/10. I was approved on 11/10/10. My BMI is 41.

[SFOTraveler 42]

CA started approving it as of 11/18/10. I was on the phone with them forever and a day today to find this out. I was planning on self paying for my surgery and now I am rushing to get in a pre-auth for a Dec 15 surgery!!!!

[warrior68 16]

Thank you everyone for the replies.

I Plan on filing my appeal before the week is out, but may have to hold off until the beginning of next week.

Long story short here, I was denied for the band back in June because I have a intestinal disease (Crohns Disease) BCBS stated they were afraid of erosion due to the band. We resubmitted the request two more times, My surgeon and I did some research, and neither lap band company was willing to help out with a appeal for a Crohns Patient. Basically there is no evidence that the band in a crohns patient would cause problems, but there is also no evidence to show it wouldn't.

Fast forward to Oct when I all the sudden I had a temp loss of vision, my BP spiked sky high, my sugar levels went through the roof. My PCP then tells me, you are a train wreck waiting to happen, and if you dont lose this weight and keep it off for good you may not be around much longer. I go back to the surgeon, we talk things over and he says, the sleeve is safer, and he can get me approved for the sleeve, we put in the request, and it got denied stating that it is experimental / investigational.

I have a list of co morbidity's a mile long

High blood pressure

Type 2 Diabetes

Obstructive sleep apnea

Acid reflux

High Cholesterol

BMI of over 46

I have a proven med history of weight loss and re gain.

And the Dr says I am a high risk for a stroke right now.

I have completed all the pre screening Dr visits, I lost more than the required 5% .

I started out at 5'7" 318lbs at my first visit to the surgeon, I now hover around the 298 -303 lb area.

My PCP is going to write a much stronger worded letter of recommendation than he did last time. I have written a letter myself that I plan on adding a list of all the BCBS divisions or entities that do cover the sleeve before finalizing it, and my surgeon and his staff are pursuing this on their end too. The nice lady that handles the insurance end of things at my surgeon says she did get one through Excellus BCBS Bluepoint 2 a couple weeks ago due to Rheumatoid arthritis, which I also have. I'm unsure what the Rheumatoid arthritis has to do with it, but it does make me somewhat hopeful.

I think the angle I'm shooting at is that a precedence has been set by approving it through other BCBS policies, especially BCBS Federal. Why in world is it ok for a Federal employee to get the sleeve, but yet its considered exploratory / Investigational for a non federal employee?

Sorry I have a habbit of rambling on when it comes to this.

I'm trying not to get to excited about being approved this time, as I hate the huge let down when I get those damn denial letters

Thanks for all the replies!

[Eureka-C 20]

I have BCBS CA ppo. I submitted for approval in June and was denied. I too appealed. I wrote a letter. It's on my blog. I think a letter backed with research and personal concerns also stating why the other surgeries are not good for you is important. Good luck. I personally found the appeal process pure hell.

[ZenBunni 0]

I have excellus BCBS Blue Point 2 insurance here in NY, I have been denied again, stating that the sleeve is exploratory / investigational. I am going to appeal the denial, and was wondering if anyone that has any type of BCBS Insurance that was approved for the sleeve to please post here with which company you have, what state you live in, and when you were approved. My thinking is that if I can provide a list of BCBS entities that have covered the sleeve, Excellus BCBS Blue point 2 could hardly then state that it is experimental or Investigational.

I posted this in a couple different threads hoping to have as many people as possible see it, sorry for the over posts.

YES. I have BCBS Anthem of CA and I got approved a week ago. My original claim was denied, investigational/experimental, so I submitted a modified copy of the letter that Fitat50 used (Ok so basically I combined a few different letters, but mainly was hers). I had to wait the mandatory 30 days, but on the last day before it expired I called and spoke with the appeals rep and he looked everything over and said "Great Letter! Yup your approved".

I am attaching the letter. You have to modify it to fit your medical conditions, and your insurance ... but worked for me. Didnt even have to take it all the way to peer review!

Stefanie

VSG Surgery Appeal Letter.doc

[warrior68 16]

YES. I have BCBS Anthem of CA and I got approved a week ago. My original claim was denied, investigational/experimental, so I submitted a modified copy of the letter that Fitat50 used (Ok so basically I combined a few different letters, but mainly was hers). I had to wait the mandatory 30 days, but on the last day before it expired I called and spoke with the appeals rep and he looked everything over and said "Great Letter! Yup your approved".

I am attaching the letter. You have to modify it to fit your medical conditions, and your insurance ... but worked for me. Didnt even have to take it all the way to peer review!

Stefanie

Wow, that is a great letter!! I do plan on using it, thank you so much!!

[ZenBunni 0]

Wow, that is a great letter!! I do plan on using it, thank you so much!!

You are VERY welcome. Hey we have to stick together =)

However ... As of 11/18/10 Anthem of CA now approves VSG! (http://www.anthem.com/ca/medicalpolicies/policies/mp_pw_a053317.htm)

So you probably don't even need to file an appeal

[mandapanda003 1]

I have excellus BCBS Blue Point 2 insurance here in NY, I have been denied again, stating that the sleeve is exploratory / investigational. I am going to appeal the denial, and was wondering if anyone that has any type of BCBS Insurance that was approved for the sleeve to please post here with which company you have, what state you live in, and when you were approved. My thinking is that if I can provide a list of BCBS entities that have covered the sleeve, Excellus BCBS Blue point 2 could hardly then state that it is experimental or Investigational.

I posted this in a couple different threads hoping to have as many people as possible see it, sorry for the over posts.

I have BCBS PPO of Ill. and they approved me...after one denial and request for more info on my 3 month diet.

[kaygarr 0]

I have BCBS PPO of MI, like Susanne said they began covering the sleeve 11/1/10. I was approved on 11/10/10. My BMI is 41.

[NJMOMof2 17]

I have BCBS of NJ and was approved no problem. I was ready for a fight but it wasn't needed. I was very suprised. Keep fighting.

[apw0 7]

I have Empire BCBS/PA. I didn't necessarily get approval from them. My doc's office said that they are authorized to do the sleeve as an outpatient procedure, but more often than not, the patients stay at least overnight. If I make the decision to stay overnight, they told me that the oweness is on the hospital to get the approval. I don't know if that really helps, but I thought I would share.