Insurance Gurus...please Help

[littlebits 154]

Hello everyone! I recently finished up most my clearances for BCBS of DE...I just have one nutrition class left in May.

Immediately following my 5th nutrition class I stopped to speak with the nurse to discuss a possible surgery date. At this time, I was informed that my insurance company still views the sleeve as a two part procedure; therefore, they require a BMI of 50 or higher. My BMI is 38.

I'm not really sure why it took five months for someone to share this information with me, but I am absolutely livid! I have HBP, Type II diabetes and (discovered during one of my clearances) sleep apnea. In addition to these issues, yesterday, the cardiologist (another clearance) informed me that I have a slight heart murmur.

Has anyone else ever run into a situation like mine? Were you able to get approved? What did you do??? I'm so desperate. My PCP isn't concerned. He is sure that I will get approved & he plans to fight for me. I don't know what to do.

Nonetheless, if all else fails, I have a backup plan...

My company's open enrollment begins on May 2nd. I could change to Aetna at this time. My new insurance would be effective on July 1. Aetna requires six additional nutrition classes, but that won't be too difficult. It would just push my time frame back. Does anyone know if there is a waiting period if you switch companies? I'm a teacher & I would like to have my surgery over the summer. I wanted to have it in June. Any assistance would be greatly appreciated.

Addition vent---The only issue, at this point, is the BMI requirement. I have been very proactive in trying to find out what I can do to get around this road block. The surgeon is wonderful, but his office staff is horrible. He is the one who suggested the sleeve in the first place. I went into his office to discuss Lap Band, and I have since realized that this is not an option. He suggested the sleeve b/c I have to take anti-inflammatory medication for my ankle & back (from a bad car accident).

I asked if it was possible to speak with the surgeon or receive a call back. The office manager refused to let me speak with him & insisted that I would not be approved. I'm sorry, but this is not her call. BCBS of DE told me that they base their decisions on a case by case scenerio. (Just an fyi of how rude the office manager is--there are three surgeons in the office & she also tried to convince me that the female surgeon was my surgeon. I have never met her, but I have met both of the males.) She was absolutely horrible. Anyway, I waited two days & still had not received a call from my surgeon so I called back. She never sent him the message...Smh!!! I'm sorry, when you are stressed or sick, you don't need the office staff making matters worse!!! The nerve of her! I will be reporting her next week...

So sorry for overloading you with so much information...I'm so stressed out right now. :'(

Little bits

[ProudGrammy 8,322]

ins. company requires a BMI of 50 or higher. My BMI is 38.

I have HBP, Type II diabetes and (discovered during one of my clearances) sleep apnea. In addition to these issues, yesterday, the cardiologist (another clearance) informed me that I have a slight heart murmur.

l

littlebits

sorry your going through these problems. I think if you have a BMI under 40 there "might" be a problem - but since you have all those morbitites - to the best of my knowledge you should be approved.

This is the only time where worse is better. Having all your medical problems is awful, but having these problems should allow you to have the sleeve surgery.

Your PHP and surgeon are in your corner - so thats terrific.

Sorry that the office staff is so cruel/mean - they are supposed to be helpful and curtious. They can't tell you if they think you will/will not be approved.

i think once you change to another insurance company you have a 3 month waiting period/not sure - - but get more info, maybe you won't have to change insurance co. and get the sleeve done sooner than later with your present ins. co, - if you could get some help with business staff or even dr. hopefully things will go your way.

wishing you luck

kathy

[Kat Crowder 34]

Hello everyone! I recently finished up most my clearances for BCBS of DE...I just have one nutrition class left in May.

Immediately following my 5th nutrition class I stopped to speak with the nurse to discuss a possible surgery date. At this time, I was informed that my insurance company still views the sleeve as a two part procedure; therefore, they require a BMI of 50 or higher. My BMI is 38.

I'm not really sure why it took five months for someone to share this information with me, but I am absolutely livid!

I would be livid, too - The person in charge of insurance at my surgeon is crappy, as well. Here is the link to the medical policy for BCBSDE - since i have BCBSIL and have been spending a lot of time checking out medical policy, I figured I could find it in a similar place for you:

https://www.bcbsde.com/ProviderPolicies/public_site/7.01.36_Obesity.htm

It states:

"The following procedures are covered for the surgical treatment of morbid obesity when all of the patient selection criteria are met.

(other procedures deleted here)

· Sleeve Gastrectomy (43775)

For the superobese patient with a BMI of ≥ 50 who is 18 years of age or older, sleeve gastrectomy is an eligible procedure as a first stage of a two-stage procedure, or as a sole definitive procedure.

A sleeve gastrectomy is an alternative approach to gastrectomy that can be performed on its own, or in combination with malabsorptive procedures (most commonly Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch). In this procedure, the greater curvature of the stomach is resected from the angle of His to the distal antrum, resulting in a stomach remnant shaped like a tube or sleeve. The pyloric sphincter is preserved, resulting in a more physiologic transit of food from the stomach to the duodenum, and avoiding the dumping syndrome (overly rapid transport of food through stomach into intestines) that is seen with distal gastrectomy. This procedure can be performed by an open or laparoscopic technique. Some surgeons have proposed this as the first in a two-stage procedure for very high-risk patients."

And then below that it lists the patient selection criteria which you have been working to meet (besides already having the BMI with comorbidities).

This policy could be read two ways. The 50 BMI information could be merely that - information about how the sleeve applies to 50 BMI patients, or it could be considered selection criteria. It doesn't exist in the patient selection criteria section, though, and I think that implies that it's informational. The descriptions of the other procedures don't provide any selection criteria.

The insurance companies make it difficult for you to involve yourself in the insurance approval process, which is frustrating. BCBS-IL has a peer-to-peer line where your doctor can call to discuss the denial, but the surgeon doesn't want to deal with the insurance issues, that's theoretically what he pays his insurance staff to do. And they're not medical people, they're paperwork people.

Did you get a denial letter, or is the office staff interpreting the medical policy? If it's the latter, I would completely argue the point. Print out the policy, highlight what's relevant, and explain that the sentence about 50 BMI patients explains what it is for 50 BMI patients, and doesn't exclude its use on others.

I agree with reporting her, too. If you request to speak to the doctor, they have no right to refuse you.

[littlebits 154]

littlebits

sorry your going through these problems. I think if you have a BMI under 40 there "might" be a problem - but since you have all those morbitites - to the best of my knowledge you should be approved.

This is the only time where worse is better. Having all your medical problems is awful' date=' but having these problems should allow you to have the sleeve surgery.

Your PHP and surgeon are in your corner - so thats terrific.

Sorry that the office staff is so cruel/mean - they are supposed to be helpful and curtious. They can't tell you if they think you will/will not be approved.

i think once you change to another insurance company you have a 3 month waiting period/not sure - - but get more info, maybe you won't have to change insurance co. and get the sleeve done sooner than later with your present ins. co, - if you could get some help with business staff or even dr. hopefully things will go your way.

wishing you luck

kathy[/quote']

Thank you so much!

Little bits

[littlebits 154]

Kat, thank you so much for the information!!! I will print that information out today. The office manager has to be interpreting the policy, because I still have one more clearance (my nutrition classes) that won't be complete until next month. So, she hasn't submited my paperwork.

Little bits

[Bubbaloo10 55]

I just had my surgery on April 16. Here's what they told me prior to approval. BMI must be at least 35 with co-morbidities (HBP, Diabetes, Respiratory problems) or 40 without co-morbidities. Here's something to cheer you up: my doctor's insurance girl told me that BCBS is one of the easiest to get approval from. I had only joints breaking down and severe sleep apnea with a BMI of 41.6. I got approved in six days after submittal. Don't let anyone in the doctor's office tell you that you don't qualify. They are there to make money and your money is as good as anyone else's. Keep pushing, put your b***h hat on if you have to and stay in their face. You will be approved eventually.

[littlebits 154]

Thanks Bubbaloo! I plan to push as hard as I can. I just can't understand why BCBS of DE hasn't changed their requirements yet. It's so frustrating!

Little bits

[dkna2 13]

Thanks Bubbaloo! I plan to push as hard as I can. I just can't understand why BCBS of DE hasn't changed their requirements yet. It's so frustrating!

Little bits

Hi littlebits,

I am in the same boat as you. Ok originally I had planned on having surgery from dr Garcia in Tijuanna. But, then I thought I have insurance and my Bmi is 37.5-38 so my insurance states that if I have a comorbidity a with bmi of under 40 or no comorbidity with bmi of 40 or> then I would qualify. I went to WLS seminar 4/13 and went to my surgeon consult on4/20. The doc is sending me to a sleep study on 6/19 to see if I have sleep apnea because I snore like a growling dog(according to mu hubby). The doc agreed that the sleeve would be good for me. I told him my primary said that I have Hugh cholesterol , swollen joints, bronchitis and am prefiabetic. He said if the sleep study shows sleep apnea then I would probably get approved by BCBS OF STATE OF ALABAMA. They also don't require a 6 month supervised weight loss , which is good. But I'm gonna call the sleep lab daily because I am hoping someone will cancel and I can take their place so I don't have to wait until June . This is such a runaround and I am trying to save by not going to Mexico but I kind of feel like now I should have went on to dr Garcia. I'm getting so doggone frustrated and discouraged. Let's both hang in there and remain prayerful that we can get this surgery and start our journey to a healthy life.

Dkna2

[dkna2 13]

Thanks Bubbaloo! I plan to push as hard as I can. I just can't understand why BCBS of DE hasn't changed their requirements yet. It's so frustrating!

Little bits

Sorry for the errors in grammar teacher.

[littlebits 154]

Dkna2, I lived in AL for 8 years when I was younger. I hope that things will work out for both of us. This experience is certainly overwhelming. Lol...I don't so spell checks. Keep in touch with me & keep me posted on your progress. Good luck!

Thanks everyone for all of the great advice & encouraging words. I was down in the dumps today & all of you made me feel so much better!

Little bits

[beautifulnewme2012 164]

Littlebits...don't let the devil steal your joy. He comes to distract and frustrate....I will PRAY for you. I will pray for that Office MGR too...sheesh! How frustrating!!

[littlebits 154]

Thank you! I'm getting myself together.

Little bits

[Ms skinniness 3,003]

So if u can get approval. Can.u select the 2 step procedure and get the sleeve, then stop there. They can't force u to get an RnY. I like to think out of the box when possible. ;$

[littlebits 154]

Dorrie, I wish. I don't meet their bmi requirement for the 2 step or stand alone procedure. The nurse @ my nutritionist's office said that she was told that BCBS of DE is in the process of changing their requirements, but we don't know that for certain. I'm just going to trust my pcp & keep moving forward. Happy thoughts!!!

Little bits

[dkna2 13]

Dorrie' date=' I wish. <img src='http://www.bariatricpal.com/public/style_emoticons/<#EMO_DIR#>/wink.png' class='bbc_emoticon' alt='' /> I don't meet their bmi requirement for the 2 step or stand alone procedure. The nurse @ my nutritionist's office said that she was told that BCBS of DE is in the process of changing their requirements, but we don't know that for certain. <img src='http://www.bariatricpal.com/public/style_emoticons/<#EMO_DIR#>/sad.png' class='bbc_emoticon' alt='' /> I'm just going to trust my pcp & keep moving forward. Happy thoughts!!! <img src='http://www.bariatricpal.com/public/style_emoticons/<#EMO_DIR#>/smile.png' class='bbc_emoticon' alt='' />

Little bits[/quote']

Littlebits,

Is it the surgeon's office that submits the paperwork or is it the primary care physician ? In my case it is the surgeons office and when they submit they send the primary care physicians progress notes and in those notes the primary should have documented reasons y u need the surgery. I may be wrong though.