blue cross blue shield

[Candle 11]

APPROVED TODAY by BCBS South Carolina!

Woo-Hoo!!!!!!!!!! Congrats!!! :rockon:

I'm so happy for you - I've been keeping up on your progress.

[Lap_dancer 8]

I don't understand...you live in Kansas City area but have BCBS in South Carolina?

My company insurance booklet covers 'weight loss surgery for the morbidly obese, provided the insured meets the following criteria' (and you know what that is). However it doesn't specify the type of surgery it covers. The BCBSNC policy for Morbid Obesity is the one that excludes 'gastric banding.' I have left two messages with a BCBS rep over the last two weeks. This person has not even had the courtesy to call and say, NO or HELL NO, or, hopefully, that they are looking into it. This reminds me of getting my driver's license renewed....you have no choice....what are you going to do...go somewhere else? Arrrggghhh. JB

I have to agree with Tracy on that backwards comment. If they cover weight loss surgery but don't consider Lap Band weight loss surgery than what do they consider weight loss surgery?

[Lap_dancer 8]

Originally Posted by Lap_dancer

From BCBS Association (corporate)

.

5. The improvement must be attainable outside the investigational settings.

The improvement in health outcomes for laparoscopic gastric bypass can be attained outside the investigational setting, if the training of surgeons and the programmatic elements are similar to programs in the published literature, and if performed at a hospital with sufficient surgical volume. However, there may be considerable variation in capabilities and resources among different bariatric surgery programs. To address this concern, Blue Cross and Blue Shield Association and the American College of Surgeons have developed criteria for credentialing and tracking outcomes from bariatric surgery programs.

Based on the above, laparoscopic gastric bypass meets the TEC criteria, when performed in appropriately selected patients, by surgeons who are adequately trained and experienced in the specific techniques used, and in institutions that support a comprehensive bariatric surgery program, including long-term monitoring and follow-up post-surgery.

http://www.bcbs.com/betterknowledge/.../20/20_15.html

Source found at above website.

Yeah, but isn't this just for gastric bypass? I couldn't find anything about gastric banding in this document. JB

..................................................................................................

Airman, think of doing searches on this subject like a crossword puzzle.

Just because you have a th_ _ K doesn't mean the word is think.

You won't find some of the information easily. You should keep track of your searches via your search engine history. Book mark things, reduce the screen and open up another window to continue a new search. Open WORD and copy and paste links and language from documents. ( I do this all the time when I am researching).

I'm not an insurance agent but here is what I have learned about Blue Cross and Blue Shield. Blue Cross and Blue Shield (BCBS) is like a mall.

Inside the mall you have different stores that you can shop from. So you get Blue Cross, Blue Shield, Blue, Blue Options, ...

Google is a good friend. Please utilize this in your efforts to gain information available to you.

Google entry from me was: BCBS South Carolina weight loss surgery

HITS: Suburban Surgical Care Specialists, S.C. - Bariatric Surgery

Vanderbilt Center for Surgical Weight Loss, Exclusion List

The Next Step for Weight-Loss Surgery

Blue Distinction Centers for Bariatric Surgery

That one sounds good, I think I'll try it.........

(thinking, if BCBS doesn't cover it and thinks Lap Band

is experimental, I won't find a hit on my search )

Inside this HIT I see it is the BCBS site, I'l go to SEARCH

and type in GASTRIC

HIT:

Displaying results 1 - 5 of 5 items found.

1. TEC in Press - Laparoscopic Adjustable Gastric Banding for Morbid Obesity

(Web Page; Thu Jan 25 15:43:00 EST 2007)

EXECUTIVE SUMMARY Background: Bariatric surgery leads to substantial amounts of weight loss in morbidly obese patients, and this weight loss leads to net improvements in health outcomes. Among different surgical procedures,...

Description: Laparoscopic Adjustable Gastric Banding for Morbid Obesity

2. Laparoscopic Gastric Bypass Surgery for Morbid Obesity

(Web Page; Mon Oct 30 15:26:00 EST 2006)

Assessment ProgramVolume 20, No. 15 February 2006Executive Summary Background Bariatric surgery leads to substantial amounts of weight loss in morbidly obese patients, and evidence exists that this weight loss leads to net...

Description: Bariatric surgery leads to substantial amounts of weight loss in morbidly obese patients, and evidence exists that this weight loss leads to net improvements in health outcomes.

3. Newer Techniques in Bariatric Surgery for Morbid Obesity: Laparoscopic Adjustable Gastric Banding, Biliopancreatic Diversion, and Long-Limb Gastric Bypass

(Web Page; Mon Oct 30 15:27:00 EST 2006)

Assessment ProgramVolume 20, No. 5 August 2005Executive Summary Morbid obesity, generally defined as a body-mass index (BMI) of 40 kg/m2 or greater, is associated with excess mortality and a high burden of obesity-related morbidities....

Description: Morbid obesity, generally defined as a body-mass index (BMI) of 40 kg/m2 or greater, is associated with excess mortality and a high burden of obesity-related morbidities.

HIT:

TEC in Press - Laparoscopic Adjustable Gastric Banding for Morbid Obesity

EXECUTIVE SUMMARY

Background: Bariatric surgery leads to substantial amounts of weight loss in morbidly obese patients, and this weight loss leads to net improvements in health outcomes. Among different surgical procedures, gastric bypass is the most common procedure performed in the U.S., and offers the most favorable benefit/risk ratio among established procedures. Laparoscopic adjustable gastric banding (LAGB) is an alternative technique that has the potential advantages of being less invasive and reversible. Prior TEC Assessments have concluded that LAGB does not meet the TEC criteria.

Objective: To review the available evidence on whether LAGB results in similar improvements in health outcomes as does open or laparoscopic gastric bypass (GBY).

Search strategy: MEDLINE search for the period of 1980 through September 2006, supplemented by hand search of bibliographies and search of Cochrane database.

This goes on but it tells me that they are NOT calling it "investigational." PRINT AND SAVE

1. The technology must have final approval from the appropriate governmental regulatory bodies.

Bariatric surgery itself is a procedure and is not subject to U.S. food and Drug Administration (FDA) regulations. However, certain devices that may be used as part of the procedure may be subject to FDA approval. The Lap-Band® system received premarket application (PMA) approval by the FDA in June 2001 for use in morbidly obese patients.

2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes.

The evidence is sufficient to permit conclusions concerning the short-term safety and efficacy of LAGB in comparison with GBY. Weight loss at 1 year following LAGB is substantial, in the range of 40% EWL, although less than that seen following GBY. The short-term complications of LAGB are very low, with serious short-term complications being uncommon, and mortality exceedingly rare. Rates of short-term adverse events, including serious procedural complications and mortality, are lower for LAGB compared with GBY.

Same page, further on down the page.

Airwayman, I could truthfully sit here for the next span of time and do this research for you but in the end, it teaches you nothing on perserverance. I am a teacher. I teach my students that perserverance pays off. In the frustration of learning, there is victory in the end.

*I began my own Quest knowing NOTHING about the surgery, my own insurance plan nor how the process works. After six months, I can answer pretty much any question thrown my way. Tomorrow I will get my chance to educate the insurance committee at work. They were told "gastric surgery is not covered by Blue Cross", I beg to differ.

http://mcgs.bcbsfl.com/

Search: Medical Coverage Guidelines BCBS

HIT:

1.(61.06% Relevant)Gastric Electrical Stimulation... peripheral or gastric neurostimulator pulse generator or receiver, direct or inductive coupling 64595 Revision or removal of peripheral or gastric neurostimulator pulse generator or receiver 0155T Laparoscopy, surgical, implantation or replacement of gastric stimulation electrodes, lesser curvature ...2.(59.05% Relevant)Gastric Bypass Revision... gastrectomy or intestine resection; with vagotomy 43886 Gastric restrictive procedure, open; revision of subcutaneous port component only 43887 Gastric restrictive procedure, open; removal of subcutaneous port component only 43888 Gastric restrictive procedure, open; removal and replacement of ...>>3.(58.83% Relevant)Surgery for Clinically Severe Obesity... or stapling along the horizontal or vertical axis). Unlike the traditional gastric bypass, which is essentially a gastric restrictive procedure, these very long limb Roux-en-Y gastric bypasses combine gastric restriction with some element of malabsorptive procedure, depending on the location of the ...

02-40000-10

Original Effective Date: 10/15/99

Reviewed: 04/27/06

Revised: 05/15/06

Next Review: 04/26/07 Subject: Surgery for Clinically Severe Obesity (Bariatric Surgery; Gastric Bypass Surgery)

THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION.

Non-Covered Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines Other References Updates DESCRIPTION:

Clinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. For purposes of this medical coverage guideline, clinically severe obesity is defined as a body mass index (BMI) of 35 kg/m2 or greater. See the height and weight tables for Men and Woman, BMI tables (100-195, 200-295, 300-400, and formula for calculating a BMI. Several surgical (bariatric) procedures are used for the treatment of clinically severe obesity. These procedures can be categorized as follows:

[Lap_dancer 8]

Tell your insurance company this:

I went to our website for Blue Cross Blue Shield of South Carolina.

I went to the search engine.

I typed in TEC for the Blue Cross and Blue Shield Technology Evaluation Center

I got this: http://www.bcbs.com/betterknowledge/tec/

I typed in GASTRIC in that search engine and got this

http://www.bcbssc.com/bcbs/bcbs_memb1.nsf/resoabtf/TchnlgyEvl_TchnlgyEvltnCntr_1?opendocument

And it says:

1. TEC in Press - Laparoscopic Adjustable Gastric Banding for Morbid Obesity

(Web Page; Thu Jan 25 15:43:00 EST 2007)

EXECUTIVE SUMMARY Background: Bariatric surgery leads to substantial amounts of weight loss in morbidly obese patients, and this weight loss leads to net improvements in health outcomes. Among different surgical procedures,...

Description: Laparoscopic Adjustable Gastric Banding for Morbid Obesity

2. Laparoscopic Gastric Bypass Surgery for Morbid Obesity

(Web Page; Mon Oct 30 15:26:00 EST 2006)

Assessment ProgramVolume 20, No. 15 February 2006Executive Summary Background Bariatric surgery leads to substantial amounts of weight loss in morbidly obese patients, and evidence exists that this weight loss leads to net...

Description: Bariatric surgery leads to substantial amounts of weight loss in morbidly obese patients, and evidence exists that this weight loss leads to net improvements in health outcomes.

3. Newer Techniques in Bariatric Surgery for Morbid Obesity: Laparoscopic Adjustable Gastric Banding, Biliopancreatic Diversion, and Long-Limb Gastric Bypass

(Web Page; Mon Oct 30 15:27:00 EST 2006)

Assessment ProgramVolume 20, No. 5 August 2005Executive Summary Morbid obesity, generally defined as a body-mass index (BMI) of 40 kg/m2 or greater, is associated with excess mortality and a high burden of obesity-related morbidities....

Description: Morbid obesity, generally defined as a body-mass index (BMI) of 40 kg/m2 or greater, is associated with excess mortality and a high burden of obesity-related morbidities.

4. TEC Assessments in Press

(Web Page; Thu Jan 25 16:07:00 EST 2007)

January 2007 The following Assessment and Special Report from the November 2006 Medical Advisory Panel (MAP) meeting are in press. Laparoscopic Adjustable Gastric Banding for Morbid Obesity Special Report: The Efficacy and Safety of...

And Now just read all of the above hits at that site.

Look for change in terminology from Investigative.

[synicalchick 0]

Well, I got my friggin insurance letter today from BCBS of TN saying that .. and I quote " Based on the information received and teh terms of your health benefit plan, we determined that the requested service is not medically necessary." Even though I had prepared myself for this.. it's still irritating. Let's review.."not medically neccessary" shall we.

• I'll be 37 tomorrow
  
• I weigh 334
  
• BMI 54
  
• I walk down the hallway and I'm out of breath and exhausted
  
• Family medical history.. diabetes both sides. HIGH LDL both sides. Father/grandfather quadruple bypass surgeries at 51 & 58. High blood pressure both sides, gall bladder problems, cancer & obesity.
  
• chiropracter visits every two weeks for lower back pain
  
• carpal tunnel aggravated by weight.
  
• been over 200 for 15 years
  
• been over 250 for 10 years
  
• been over 300 for 5 years...Hmmm I see a pattern here folks.

Gee.. I'm starting to see what they mean.. medically necessary.. PSHHH I'm healthy as a HORSE...and the size of one two... IDIOTS.

Anywho. going to talk to my surgeon tomorrow about my options, see if they'll contact the lawyers that represent the lap band people and take it from there.

[Lap_dancer 8]

Join me for a read in a contradiction in terms that is confusing at best.

Here is the site:

http://www.anthem.com/medicalpolicies/noapplication/f4/s10/t2/pw_034084.pdf

Anthem and Blue Cross Blue Shield are married in some states as one insurance company. Assuming this is your case, read this PDF document and go to PAGE ONE (P. 1)

MEDICAL POLICY

Policy Statement:

Medically Necessary:

Gastric Bypass and Roux Y procedure......keep reading..... LAP BAND...keep reading......ARE CONSIDERED MEDICALLY NECESSARY FOR THE TREATMENT OF CLINICALLY SEVERE OBESITY FOR SELECTED ADULTS..

( Okay remember that ) Now go down

Start at:

INVESTIGATIONAL / NOT MEDICALLY NECESSARY

Gastric Bypass.....keep reading.......keep reading......next paragraph...keep reading...keep reading....

All OTHER PROCEDURES NOT LISTED ABOVE* AS MEDICALLY NECESSARY ARE INVESTIGATIONAL AND NOT MEDICALLY NECESSARY.

* It reads like if Lap Band is not listed from the beginning of this passage from "Investigative/Not Medically Necessary" it isn't listed so it isn't covered. It's confusing.

[Lap_dancer 8]

Well, I got my friggin insurance letter today from BCBS of TN saying that .. and I quote " Based on the information received and teh terms of your health benefit plan, we determined that the requested service is not medically necessary." Even though I had prepared myself for this.. it's still irritating. Let's review.."not medically neccessary" shall we.

• I'll be 37 tomorrow
  
• I weigh 334
  
• BMI 54
  
• I walk down the hallway and I'm out of breath and exhausted
  
• Family medical history.. diabetes both sides. HIGH LDL both sides. Father/grandfather quadruple bypass surgeries at 51 & 58. High blood pressure both sides, gall bladder problems, cancer & obesity.
  
• chiropracter visits every two weeks for lower back pain
  
• carpal tunnel aggravated by weight.
  
• been over 200 for 15 years
  
• been over 250 for 10 years
  
• been over 300 for 5 years...Hmmm I see a pattern here folks.

Gee.. I'm starting to see what they mean.. medically necessary.. PSHHH I'm healthy as a HORSE...and the size of one two... IDIOTS.

Anywho. going to talk to my surgeon tomorrow about my options, see if they'll contact the lawyers that represent the lap band people and take it from there.

What do you have to do but time? I look at it like that. My husband is fond of saying...AW what the hell, let's appeal it just to mess with them!

It actually becomes a lesson in life and fun if you figure

A. It won't cost me a dime.

B. I will learn something from this.

C. What if I'm right?

Hahahha.

[ReneBean 3]

Synicalchick

Blue Cross doesn't like the BMI over 50. I was denied because of my high BMI.

I appealed and won. Hopefully, you can, too.

e-mail me with an address to mail to. I will send my letters.

[Lap_dancer 8]

Synicalchick

Blue Cross doesn't like the BMI over 50. I was denied because of my high BMI.

I appealed and won. Hopefully, you can, too.

e-mail me with an address to mail to. I will send my letters.

Same goes here Synicalchick. I've got all my letters on WORD at work. Would be happy to send you what I have.

[2bthinagn 3]

APPROVED TODAY by BCBS South Carolina! Documentation including psych and nutrition evals were faxed Friday morning, and my doc got the approval call today. Waiting on the scheduler from the surgeons office to call with a date, and yes in my company's medical SPD BOTH the bypass and gastric banding are spelled out as approved, and yes it had to be medically necessary.... meaning a BMI over 40, or 35 with 2 comorbitites. I qualify with a BMI over 40, and have NO serious comorbitities... The doc has to submit your BMI (to qualify for medically necessary) and yes BCBS will pay for it, because my docs office called them after my consultation and specifically asked them if they covered it and what was required for determination. YIPPPPPPEEEEEEEE FOR ME!

Heh way to go......congrats. I am anxious to see how fast you get a surgery date!

[itsteri 0]

Anyone have BCBS HealthSelect of Texas? I am a State of Texas employee and was told by BCBS that lap band was not covered. Just wondering if anyone has been approved by this type of BCBS insurance.

[TracyinKS 7]

Put an update in my BCBS SC thread....

I found a TYPO on on my online authorization!!!!!!!!!!!

says my authorization period is from 12/31/2007 to 01/01/2008

GRRRRRRRRRRRRR...

I have sent emails to my contact to fix this......ASAP

[Lap_dancer 8]

How goes it Trace? News? I have big news but won't know absolute until Feb. 15. Will post it if I can't wait.

LD

[TracyinKS 7]

Morning LD!!!! I did get a call from bcbs yesterday saying that they were trying to find out where the typo came from.. apparently on the FSA system it shows the right dates, turns out they may end up doing a complete audit of the system to see if it is glitch....

No word from the surgeons scheduler yet.... I am waiting as patiently as I can..

WHAT IS YOUR NEWS!!!! I CAN NOT WAIT TIL THE 15TH!!!!!

[Lap_dancer 8]

Morning LD!!!! I did get a call from bcbs yesterday saying that they were trying to find out where the typo came from.. apparently on the FSA system it shows the right dates, turns out they may end up doing a complete audit of the system to see if it is glitch....

No word from the surgeons scheduler yet.... I am waiting as patiently as I can..

WHAT IS YOUR NEWS!!!! I CAN NOT WAIT TIL THE 15TH!!!!!

Okay

Here is my news.

You all know I followed my BCBSFL appeals process all the way to the top and then called the State Dept of Insurance regarding my denial.

The denial was based soley on my employer's policy. They have an exclusion for gastric surgery. It's as plain as the nose on your face.

I was told by one employee of BCBS that the employer could buy the inclusive procedure and add it to my policy. SO... I called employee benefits and explained, sent copies, and contacts at BCBS, and then got an appt. to sit before the Insurance Committee to request the purchase of this to my contract.

This happened on Wednesday.

I felt so calm, like I had nothing to lose (but my weight). This committee made me feel welcome. One half hour turned into an hour. I don't think there was one person on that panel who couldn't relate. We all know people who try and try to lose weight in vain. I told them my story and then I showed them my ziplock bag of 9 medications I take each day.

My request was a first. They didn't know if it was doable, BCBS reps were present and said they could draft the inclusion and would have it within a few days. One person was checking with the attorney to see if there was a problem, and the other was checking with the Board for expenditure approval. They will reconvene on Feb. 15th to submit findings.

I'm feeling really good about this. :high5: :high5: :high5: