BCBS - What are they thinking?

[NJChick 3]

I have bcbs of nj, they did approve me but not until 3 days before my surgery, talk about high blood pressure. As all the folks here know, they kept me on pins and needles lol.

[ladysplenda 1]

Both Mandy and I got turned down three times.You have to keep appealing after the third turn down go before the insurace board. They will approve alot of times then. I was told that if they are found in the wrong they have to pay fines.They do not like to go before the insurance board.

[dolphin_dreams 0]

Mert,

I'm sorry you're having such a frustrating time with the approval process. I wanted to hopefully give you some hope. I am a Texas teacher with TRS plan 2 and I was approved. 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."

September 26- I received a vague letter stating that BCBS covered Lap Band surgery. It did not, however, say that I was approved. I talked to my wonderful nurse, Barbara and she said that what a letter like that means is that you have to schedule the surgery and wait to be pre-authorized.

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

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

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.

I was hoping to be approved before September 1st since that is when our deductable starts over but that didn't happen. My doctor's office said that they weren't surprised since BCBS usually takes at least 6 to 8 weeks. I was also told that they(BCBS) also will not except faxes . Everything has to be mailed from the doctor's office.

I hope this helps. Good luck and keep us posted.

[Desi80 1]

I have BCBS VA - ppo and was approved very quickly. I love my insurance i've never ever had a problem with them approving anything, and always had great customer service. I plan on writting them a letter on my one year bandiversary thanking them!!

I had a BMI over 40 and several co-morbidities.

[patty103 0]

i have bcbs of TN and got approved as soon as they got all the paperwork morbities and all. i had over 150 pounds to lose, I got the approval without a medically supervised weight loss whatever. but I did have the diet history and every thing turned in. couldn't get my DH's insurance to approve me because I didnt have this medically supervised weight loss, HOWEVER once I had the surgery BCBS has been a pain to deal with, denying everything and I have to call and get it resubmitted and my DH's insurance gives no trouble paying. I think I will drop BCBS again next year, I am paying out for nothing..... I also despise that company and they did approve me.

[Mert 0]

Mert,

I'm sorry you're having such a frustrating time with the approval process. I wanted to hopefully give you some hope. I am a Texas teacher with TRS plan 2 and I was approved. Here is a timeline of how things went for me.

Dear dolphin_dreams, thank you for the good news. What did you have for documented medically supervised weight loss attempt? Did you give them a written history or receipts or doctor notes or all of the above. My PCP is faxing stuff to BCBS and hopefully it will include in his office notes how we talk about diet every time I go in there. Also sent office notes from endocrinologist and plan to send internal specialist office notes and lab results also. Thank you so much for sharing your experience and time line with me. Maybe I just need to have patience and jump through their hoops before griping about them. It is difficult to wait once my mind is made up about this. It would be perfect to get it done in the summer and have lots of time to recuperate before class resumes...but people take off for surgery all the time and maybe I can combine with a holiday or take Family Medical...how long after surgery were you able to return to the classroom?:nervous nervously waiting, mert

[Mert 0]

Dolphin Dreams, did you even have to prove weight loss attempts, medically supervised? I am on plan 3, the supposedly best one, or at least most expensive.

Here is what they asked for from me:

1)History and physical info incl. height, weight, and co-morbidities

2)Initial Evaluation

3)Documented history of morbid obesity (5 years)

4)evidence of at least 12 consecutive months of medically supervised, non-surgical methods of weight reduction with documentation that such efforts failed. the supervion must be provided by an MD, DO, or Nurse Practitioner. The weight reduction methods must include nutrition therapy, behavior modifying exercise or increase in activity, medication therapy and maintenance therapy.

5)psych evaluation

6) Documentation of willingness to comply with pre-op and post-op treatment plans

7)Documentation of procedures to be performed, with pertinent CPT codes.

#4 is the tough one. the doctor in the network, Dr. Davis does provide a medically supervised weight program that costs for 6 months....$3800. I called and asked BCBS if they would pay for this (spoke to Meriah on 6/27/06) and she said "NO". hooboy:faint: Then I spoke to Janis, supervisor who Meriah transferred me to. I told her I had been to one doctor or another almost every month for the past year. I asked her did it have to be every month. Janis said no. Janis can look at their records of pay outs and see when I went to the doctors. Did they ask you for all this too?

It is true I have been to doctors alot b/c I'm sick and worried about this metabolic problem and continual weight gain...:sick

I'm sick and tired of being fat, sick and tired. OK this tirade is over:clap2:

If you are still with me thank you for reading all this mess.

[ericsmom 2]

I have BCBS of WI and was approved. There is another employee in the same school that I work in that had the band a little more than 2 months ago, so I knew it would be covered. There are also other school district employees that have had the full GB. I had to go through about 8 hoops, but I got the approval. I can't believe I go day after tomorrow!!!

[Mert 0]

Thanks Ericsmom,

So that looks like a normal list of hoops to jump for the insurance company?

I will keep you in my prayers on the 5th and congratulations on your surgery date. Please let me know how it goes. mm

[Mert 0]

Ok Everybody, it occurs to me that I am being too whiney and I need to just do it.:straight

[Randi 0]

MaryB,

I've never heard of having to have 5 years of documented weight loss efforts. Although, I have read that the person must have been overweight for at least 5 years as part of the criteria for surgery and normally you're required to self-report the diets you've been on in the past. Maybe she misread or misunderstood the information she was given?

If not, past visits to the doctor's office may prove helpful in her situation because the first thing they have you do is get on the scale. That tidbit right there may be enough to fill the requirement.

Good for you, Elisabeth! I did tell the nice lady in the salad bar line to not give up after one denial. I think she was discouraged because she was told she had to have at least 5 years of documented weight loss efforts in the past plus the extra six months Doctor supervised diet. How many people have this kind of paper work around? Not me...even though I have been on and off diets since I was 13... That is 35 years of diet failures!

[wantlapband 0]

How is BCBS New England? Do they take long for approval?

[dolphin_dreams 0]

Mert,

Sorry it took me a few days to reply. I've haven't been on the computer much due to the 4th Holiday.

Most of your list of requirements sound like mine. I don't, however, ever remember being asked to provide documentation of willingness to comply with pre-op and post-op treatment plans. I see my surgeon every six weeks for a checkup. Maybe this counts as follow-up.

Regarding the 12 month diet, I was on a supervised diet through my OB/GYN for a little over a year about 2 years ago. I had to go to the doctor once a month in the beginning but not every month the whole time.

I also sent in the records from my PCP in which he checked my weight each visit as well as records from my Podiatrist. My ankles were killing me and I had to have orthotics made because my weight, along with my flat feet, were breaking down the bones in my feet. Every little bit of information you can send them helps. Sometimes, people forget to mention joint pain such as knees and ankles. Also, my doctor asked me about back pain. All of these these things are effected by weight.

In response to the 5 year weight history, I simply wrote down all the different diets that I had tried over the years. For example: low fat, Atkins, Cabbage Soup diet, Weight Watchers(I didn't go to meeting but I ate the meals and tried to follow the plan), South Beach etc.. Unless you are one of those who kept a weight loss journal(I wasn't), you have to guess or estimate how many months you were on the various diets.

Please don't think that you are being too whiney. We are here to support you and all of us have been there so you're not alone. Don't give up!!:hug:

[ReneBean 3]

It took four months and a trip before the insurance board - but BC/BS of CA did approve me... and so far they have paid for almost everything. My total out of pocket so far is well below $1000.

Keep fighting. ***IF they will cover Gastric Bypass for you, you CAN make them cover the band. E-mail me if you want copies of my appeal letters.

Good Luck!!

[Mert 0]

thank you, Jesus!! I have now been approved by BCBS of TX TRS Activecare. The nice lady who I had been corresponding with at BCBS called yesterday. I have an appt. with the surgeon on the 18th. I feel so lucky. Thank you for listening to me while I waited impatiently for approval.