Carefirst Bcbs (maryland) Bmi 41?

[tasherie 35]

I really want the sleeve. I was originally researching the RNY, but with all the research and information decided to go with the sleeve for a lot of reasons. Now to my question, I have heard that Carefirst only does the sleeve for a 50 or over BMI? I am coming to the end of all of my insurance hurdles and I am really getting nervous that I will be denied because of a low bmi (for sleeve). Does anybody have any experience with Carefirst?

[lisahg 9]

Hi

I am unfamiliar with Carefirst but I ran into the same issue with my BCBS insurance Highmark (Pa.) They did cover VSG for patients with a bmi of 50+ as the 1^st in a 2-stage surgical treatment (the 2^nd being RNY) performed after the patient lost enough weight with the VSG to make the 2^nd surgery less risky. I was kind of aware of this policy as I went through the other insurance requirements having a bmi just below 40 with 2 comorbidities. I expected and was denied coverage from Highmark because of the 50bmi stipulation and deeming my surgery not medically neccessary. My surgeon even participated in a peer-to-peer review with Highmark in hopes of reversing the decision with no luck. I have other medical issues that made the Lap-band and RNY (which I could most likely be approved for without much drama) not good choices for me. Highmark didn’t care.

After going through 2 appeals with no success. I then had the option to request an external appeal where all your information and the insurance's information is sent out to an Independent Review Organization (IRO) to finally rule on the case. I am happy to say that the IRO overturned Highmark’s decision to deny and they were required to cover my surgery. The committee basically said to Highmark, "The vsg is among the surgical treatments you cover, this patient has met all of the criterion for morbid obesity, the 50bmi is arbitrary, give this girl her darn surgery!" Lol, I embellished that last part!

I guess what I am saying is expect to fight and dont give up if the sleeve is what you really want. At the end of the day insurance companies are in the business of making money and I think they bank on people giving up when told no. I feel very lucky that the IRO ruled in my favor. I don’t take that for granted for a moment. From the research I have done external reviews result in overturned decisions around 40% of the time. So it is worth a shot. I did tons of research when preparing my external appeal letter. I had about 15+ medical studies, journal articles and position statements that I cited and used to substantiate my arguments. My husband said my letter was more like a research paper.

I'm sorry I didnt mean for this post to be all about me I just thought maybe hearing my experience would help. If you end up having to go the appeal route, I would be happy to lend any support but you have to be patient and let the process run its course. My appeals together lasted 3 months. I do think you are in a better position to appeal since your insurance does cover VSG albeit for higher bmi patients than an insurance that still views VSG as investigational. Good luck!

[Shellyac 22]

If you do get denied, you can appeal based on a recent ASMBS position paper which now recommends the sleeve as a primary surgery. The position paper came out in October of last year, so there is a chance that BCBS hasn't updated their policy requirements yest (the 50 bmi is based on a previous position paper) Good luck

[lisahg 9]

I agree with Shellyac. I forgot to mention the American Society for Metabolic and Bariatric Surgery (ASMBS) www.asmbs.org. Its an excellent resource. I cited that very position statement Shellyac mentioned in my appeal letter.

[tasherie 35]

_{Thank you so much! Heres to praying that the process isn't long and drawn out, but I am prepared to fight. Mostly, because I do not want to have a surgery that I am not completely comfortable with just because some insurance company thinks I should.}