blue cross blue shield

[Lap_dancer 8]

So, I was turned down by my insurance company - Empire BC/BS, in NYC.

Apparently, my BMI is too high for their criteria for LB; they claim it's not clinically proven to be valuable at my size (BMI 58, I think). It's slightly disastrous, because my surgery was scheduled for 3/15, and I've arranged my work schedule around that date (very difficult to do, high stress profession blah blah blah). And the surgical coordinator is away until 2/28 - I should be starting the preop liquid diet the next day.

So now what do I do? I am going with Dr. Fielding at NYU in NYC. Empire BC/BS said they'd send me a rejection letter with details for appealing.

Any advice?

My BMI is 61. I've had two surgeons tell me I need to get that bad boy number down for my own health's sake and to shrink my liver for the surgery.

you will read about detoxing on here. Detox diet to purge your system of the nasty junk in your liver (fatty stuff). I have to do this anyway and I'm self paying and getting my sugery.

Appeal that decision but the criteria they may have you under the thumb on. I wouldn't give up because I think the person who told you there was no proof LB was beneficial at your size was full of it and showed what little they did know when they made that comment. (people can be so self serving to their company..anyway) What idiot would say a weight loss surgery would not be beneficial to a very severely obese person?????

HELLO! That's like saying the patch won't work for a really super heavy smoker.

Check out the BCBS thread on here. I have mega posts from my appeals process. I have a specific exclusion in my contract that does not cover weight loss surgery "no matter what" but I still appealed. Feel free to tap my info posted there.

[Leecelove70 0]

Iam so sorry to hear of all the problems so many of you are having with Blue Cross /Blue Shield of New York. My BMI before surgery was like 45 I think ( I really do not remember its was so long ago). I was 290 pounds back then when the approval process was done in May of 2006. I recieved my approval on June 1,2006 and had my surgery on June 13, 2006.

I have lost 57 pounds as of Feb.8th, my 8 month follow up.

I do know that I got the answers I needed when I became very assertive and spoke to a Medical Management representative. This is not the same person for regular Empire claims but a seperate department.

Medical Management deals with all surgical claims and pre-certifications. They also can tell you their guidelines and where to find them on the site.

I just feel so bad for those of you who are having so much trouble with them, my experience was good.

As for the person with the very high BMI, I do not know who you spoke with, but I would have asked to speak to a supervisor, no one should speak to you like that!

To all of you I wish you good luck in your journeys--- you have my love and support!

Lisa

Banded 6/13/06

Dr.Daniel Davis

Lawrence Hospital

Bronxville,NY( Westchester County)

[Leecelove70 0]

Congratulations!!!!!

CONGRATULATIONS!

I know that feeling when you get the call, I got my call on June 1, 2006 and had my surgery on June 13,2006.

Iam now 57 pounds out as of my 8 month follow up on Fe. 8th!

Good Luck.

By the way I have Empire BC/BS PPO of NY!

Love, Hugs and Support,

Lisa

Dr.Daniel Davis

Lawrence Hospital

Bronxville, NY ( Westchester County)

[Leecelove70 0]

Lap-Banding WILL be covered by BCBS in 2007. Per changes in the 2007 Benifit Book.

Ron:

Does that include Empire PPO? I had my surgery on June 13th, 2006 and was approved on June 1, 2006. I was just wondering for in the future in case I have any problems? I am guessing it depends on what form of Empire that you have.

Iam under my husbands insurance, he works in an hospital.

Thanks for the heads up.

Lisa

Baned 6/13/06

Dr.Daniel Davis

Lawrence Hospital

Bronxville, NY( Westchester County)

[adorable 1]

Many of the plans list which comorbidities they will accept and they don't care about the others...your sex life or self-esteem, for example.

But, at 100 pounds overweight, you need a (pain the the ass) sleep study. In fact, some surgeons (or anesthesiologists) require one before surgery. Sleep apnea is a life-threatening condition and most people who have it don't know it. (Some of us even INSIST we don't have it...right before we test out as having SEVERE sleep apnea. Duh, me...)

That is so wonderful to hear! I go for my first seminar on Tuesday and from past posts it appears that Blue Cross of CA used to give people problems with approvals. My BMI is 46 and I have comorbidities such as arthritis, hypertension, hyperlipidemia, GERD and I firmly believe I may have sleep apnea although I've never been tested for it. Hopefully this will be enough to get me approved. Any suggestions would be appreciated! Wish me luck!

Denise

Still researching the lapband :help:

[adorable 1]

Mine isnt BCBS...it's BC CA PPO, but I wanted to point out that it changes fairly quickly. Here's from my BC site:

Medical Policy

Subject: Surgery for Clinically Severe Obesity

Policy #: SURG.00024 Current Effective Date: 11/13/2006

Status: Reviewed Last Review Date: 09/14/2006

Description/Scope

Clinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. There are a variety of surgical procedures intended for the treatment of clinically severe obesity. This policy addresses those procedures.

Policy Statement

Medically Necessary:

Gastric bypass with a Roux Y procedure up to 150 cm, laparoscopic adjustable gastric banding (the Lap-Band® System), vertical banded gastroplasty, or biliopancreatic bypass with duodenal switch as a single surgery, is considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet the following criteria:

1. BMI of 40 or greater, or BMI of 35 or greater with co-morbid conditions including, but not limited to, life threatening cardio-pulmonary problems (severe sleep apnea, Pickwickian syndrome and obesity related cardiomyopathy), severe diabetes mellitus, cardiovascular disease or hypertension. AND

*Note: Individuals considering the laparoscopic adjustable gastric banding (Lap-Band®) procedure must meet the above minimum BMI requirement and, in addition, have a maximum BMI of less than 50.

Ok, I just found on my policy that bariatric surgery IS covered...if you're "morbidly obese" which in medical standards I am lol...

So then I searched until I found the Blue Cross Utilization Management Guidelines which says the following (just more of what you posted above):

Medical Policy

Subject: Surgery for Clinically Severe Obesity

Effective Date: 09/14/2006

Last Review Date: 11/13/2006

Policy #: SURG.00024

Current Status: Reviewed

Description/Scope

Clinically severe obesity is a result of persistent and uncontrollable weight gain that

constitutes a present or potential threat to life. There are a variety of surgical

procedures intended for the treatment of clinically severe obesity. This policy

addresses those procedures.

Policy Statement

Medically Necessary:

Gastric bypass with a Roux Y procedure up to 150 cm, laparoscopic adjustable

gastric banding (the Lap-Band® System), vertical banded gastroplasty, or

biliopancreatic bypass with duodenal switch as a single surgery, is considered

medically necessary for the treatment of clinically severe obesity for selected adults

(18 years and older) who meet the following criteria:

1. BMI of 40 or greater, or BMI of 35 or greater with co-morbid conditions

including, but not limited to, life threatening cardio-pulmonary problems

(severe sleep apnea, Pickwickian syndrome and obesity related

cardiomyopathy), severe diabetes mellitus, cardiovascular disease or

hypertension.

*Note: Individuals considering the laparoscopic adjustable gastric banding

(Lap-Band®) procedure must meet the above minimum BMI requirement and,

in addition, have a maximum BMI of less than 50.

AND

2. The patient must have actively participated in non-surgical methods of weight

reduction; these efforts must be fully appraised by the physician requesting

authorization for surgery.

AND

3. The physician requesting authorization for the surgery must confirm the

following:

* The patient’s psychiatric profile is such that the patient is able to

understand, tolerate and comply with all phases of care and is

committed to long-term follow-up requirements; and

* The patient’s post-operative expectations have been addressed; and

* The patient has undergone a preoperative medical consultation and is

felt to be an acceptable surgical candidate; and

* The patient has undergone a preoperative mental health assessment and

is felt to be an acceptable candidate; and

* The patient has received a thorough explanation of the risks, benefits,

and uncertainties of the procedure; and

* The patient’s treatment plan includes pre- and post-operative dietary

evaluations and nutritional counseling; and

* The patient's treatment plan includes counseling regarding exercise,

psychological issues and the availability of supportive resources when

needed.

For revision of a gastric restrictive procedure for clinically severe obesity, there must be documentation of a failure secondary to a surgical complication such as fistula, obstruction or disruption of a suture/staple line, and is subject to the same criteria listed above.

:amen:

Blue Cross of California_ Medical polices and Clinical UM Gui....pdf

[airwayman 2]

That is so wonderful to hear! I go for my first seminar on Tuesday and from past posts it appears that Blue Cross of CA used to give people problems with approvals. My BMI is 46 and I have comorbidities such as arthritis, hypertension, hyperlipidemia, GERD and I firmly believe I may have sleep apnea although I've never been tested for it. Hopefully this will be enough to get me approved.

Denise, and others, I think each BCBS entity has it's own set of policies. I am looking at the North Carolina policy...it says Blue Cross Blue Shield of North Carolina, Corporate Medical Policy, Surgery for Morbid Obesity. The first issue is not with BCBS, however, it's with your company plan. If it excludes WLS you are probably screwed. If it includes WLS then it depends on the particular BCBS. My case is a perfect example. My company's policy included WLS, BUT, BCBS of NC specificially EXCLUDED "gastric banding." Not knowing this, I went for my evaluations and Dr. appt. 3 years ago. Two things changed my mind. First, the doctor had only done 7 lap bands and second BCBS called gastric banding "investigational." They don't cover "investigational" procedures. Then a year or so ago, I started hearing of people with BCBS who were being approved for the lap band. I couldn't believe it...I checked NC...nope, still same investigational status. Then about a month ago, voila!!, the policy changed to include "gastric banding," i.e., the Lap Band. I have my Dr. appt. this Friday. JB

[Lap_dancer 8]

Denise, and others, I think each BCBS entity has it's own set of policies. I am looking at the North Carolina policy...it says Blue Cross Blue Shield of North Carolina, Corporate Medical Policy, Surgery for Morbid Obesity. The first issue is not with BCBS, however, it's with your company plan. If it excludes WLS you are probably screwed. If it includes WLS then it depends on the particular BCBS. My case is a perfect example. My company's policy included WLS, BUT, BCBS of NC specificially EXCLUDED "gastric banding." Not knowing this, I went for my evaluations and Dr. appt. 3 years ago. Two things changed my mind. First, the doctor had only done 7 lap bands and second BCBS called gastric banding "investigational." They don't cover "investigational" procedures. Then a year or so ago, I started hearing of people with BCBS who were being approved for the lap band. I couldn't believe it...I checked NC...nope, still same investigational status. Then about a month ago, voila!!, the policy changed to include "gastric banding," i.e., the Lap Band. I have my Dr. appt. this Friday. JB

WOOHOO!!! JB. I'm so happy for you!!!

[MEW 0]

Congratulations JB!!!!!

[TEXUN1 0]

CONGRATULATIONS TO EVERYONE!! I can not wait for my first apt on 3/1.

[DIVAPLUSS 0]

IM DESPERATLEY NEEDING THE LAPBAND SURGERICAL PROCEDURE. I AM RAPIDLY APPROACHING 450LBS AND I AM 25 YOA. I HAVE CALLED MY INUSURANCE AGENCY SEVERAL TIMES TO FIND OUT IF IT IS COVERED. I AM WITH BC/BS SC. I GET THE SAME REPLY OF NO WE DON'T COVER THAT EACH AND EVERYTIME I CALL. I HAVE ALWAYS BEEN A HEALTHY PERSON EVEN WITH MY WEIGHT. I LEAD A NORMAL LIFE AND CARRY MY WEIGHT WELL, BUT I HAVE RECENTLY BEEN DIAGNOSED WITH HIGH CHOLESTEROL AND BORDER LINE DIABETES!! RIGHT NOW I'M CONCERNED!! PLEASE HELP..IS MY INURANCE CO. TELLING ME A LIE. I HAVE TRIED EVERY TYPE OF DIET YOU CAN IMAGINE. DIETS THAT EVEN MAKE ME PUKE EVERYTIME I EAT THE MEALS PRESCRIBED. I'M AT WITS ENDS. I HAVE A 2 YR OLD AND I'M AFRAID I WON'T BE ABLE TO INTERACT WITH HIM LIKE I WANT TO IN THE FUTURE. ANY INFO, I WILL USE TO MY ADVANTAGE, PLZZZZZZZZZZZZZZZ! :help: IT BRINGS ME TO TEARS THAT YOU WORK ALL THESE YEARS AND PUT IN SO MUCH TIME WITH YOUR EMPLOYER AND NEVER REALLY BE SICK AND WHEN YOU DO NEED THEM IT'S TRIALS AND TRIBULATION TIME. UUUUUUUGGGGGGGGHH:think

[DIVAPLUSS 0]

IM DESPERATLEY NEEDING THE LAPBAND SURGERICAL PROCEDURE. I AM RAPIDLY APPROACHING 450LBS AND I AM 25 YOA. I HAVE CALLED MY INUSURANCE AGENCY SEVERAL TIMES TO FIND OUT IF IT IS COVERED. I AM WITH BC/BS SC. I GET THE SAME REPLY OF NO WE DON'T COVER THAT EACH AND EVERYTIME I CALL. I HAVE ALWAYS BEEN A HEALTHY PERSON EVEN WITH MY WEIGHT. I LEAD A NORMAL LIFE AND CARRY MY WEIGHT WELL, BUT I HAVE RECENTLY BEEN DIAGNOSED WITH HIGH CHOLESTEROL AND BORDER LINE DIABETES!! RIGHT NOW I'M CONCERNED!! PLEASE HELP..IS MY INURANCE CO. TELLING ME A LIE. I HAVE TRIED EVERY TYPE OF DIET YOU CAN IMAGINE. DIETS THAT EVEN MAKE ME PUKE EVERYTIME I EAT THE MEALS PRESCRIBED. I'M AT WITS ENDS. I HAVE A 2 YR OLD AND I'M AFRAID I WON'T BE ABLE TO INTERACT WITH HIM LIKE I WANT TO IN THE FUTURE. ANY INFO, I WILL USE TO MY ADVANTAGE, PLZZZZZZZZZZZZZZZ! :help: IT BRINGS ME TO TEARS THAT YOU WORK ALL THESE YEARS AND PUT IN SO MUCH TIME WITH YOUR EMPLOYER AND NEVER REALLY BE SICK AND WHEN YOU DO NEED THEM IT'S TRIALS AND TRIBULATION TIME. UUUUUUUGGGGGGGGHH:think

[DIVAPLUSS 0]

IM DESPERATLEY NEEDING THE LAPBAND SURGERICAL PROCEDURE. I AM RAPIDLY APPROACHING 450LBS AND I AM 25 YOA. I HAVE CALLED MY INUSURANCE AGENCY SEVERAL TIMES TO FIND OUT IF IT IS COVERED. I AM WITH BC/BS SC. I GET THE SAME REPLY OF NO WE DON'T COVER THAT EACH AND EVERYTIME I CALL. I HAVE ALWAYS BEEN A HEALTHY PERSON EVEN WITH MY WEIGHT. I LEAD A NORMAL LIFE AND CARRY MY WEIGHT WELL, BUT I HAVE RECENTLY BEEN DIAGNOSED WITH HIGH CHOLESTEROL AND BORDER LINE DIABETES!! RIGHT NOW I'M CONCERNED!! PLEASE HELP..IS MY INURANCE CO. TELLING ME A LIE. I HAVE TRIED EVERY TYPE OF DIET YOU CAN IMAGINE. DIETS THAT EVEN MAKE ME PUKE EVERYTIME I EAT THE MEALS PRESCRIBED. I'M AT WITS ENDS. I HAVE A 2 YR OLD AND I'M AFRAID I WON'T BE ABLE TO INTERACT WITH HIM LIKE I WANT TO IN THE FUTURE. ANY INFO, I WILL USE TO MY ADVANTAGE, PLZZZZZZZZZZZZZZZ! :help: IT BRINGS ME TO TEARS THAT YOU WORK ALL THESE YEARS AND PUT IN SO MUCH TIME WITH YOUR EMPLOYER AND NEVER REALLY BE SICK AND WHEN YOU DO NEED THEM IT'S TRIALS AND TRIBULATION TIME. UUUUUUUGGGGGGGGHH:think

[airwayman 2]

IM DESPERATLEY NEEDING THE LAPBAND SURGERICAL PROCEDURE. I AM RAPIDLY APPROACHING 450LBS AND I AM 25 YOA. I HAVE CALLED MY INUSURANCE AGENCY SEVERAL TIMES TO FIND OUT IF IT IS COVERED. I AM WITH BC/BS SC. I GET THE SAME REPLY OF NO WE DON'T COVER THAT EACH AND EVERYTIME I CALL.

I am NO expert on this subject but I do have a few ideas to share. I wrote a post on this thread the other day in which I said you have two big hurdles to overcome and then many small ones. First big hurdle: Does your company insurance cover weight loss surgery? If they don't then you should go talk to your employer. If they do, most of them don't specify what type of WLS they cover...only that it's a covered expense. If it is covered, then you need to find/read the BCBS policy for Surgery for Morbid Obesity (ask your BCBS rep. to help you find it). Since you're in SC, you need THAT particular policy, not one from NC or anywhere else...they all seen to be a little different. The second big hurdle is SC may not yet approve gastric banding...NC just approved it a few weeks ago. Seems like many of them are now adding it to their coverage. Now for the bad news. Even if SC does allow it, you may not qualify. It is limited to BMI (Body Mass Index) of no more that 50. I don't know how tall you are but at 450 lbs. I would think you are way over 50. Have you considered gastric bypass? If your company allows WLS surely BCBS of SC covers RNY (gastric bypass) as it's been approved by almost all ins. companies for years. Good luck!! Keep after it. Don't give up. JB

[synicalchick 0]

IM DESPERATLEY NEEDING THE LAPBAND SURGERICAL PROCEDURE. I AM RAPIDLY APPROACHING 450LBS AND I AM 25 YOA. I HAVE CALLED MY INUSURANCE AGENCY SEVERAL TIMES TO FIND OUT IF IT IS COVERED. I AM WITH BC/BS SC. I GET THE SAME REPLY OF NO WE DON'T COVER THAT EACH AND EVERYTIME I CALL. I HAVE ALWAYS BEEN A HEALTHY PERSON EVEN WITH MY WEIGHT. I LEAD A NORMAL LIFE AND CARRY MY WEIGHT WELL, BUT I HAVE RECENTLY BEEN DIAGNOSED WITH HIGH CHOLESTEROL AND BORDER LINE DIABETES!! RIGHT NOW I'M CONCERNED!! PLEASE HELP..IS MY INURANCE CO. TELLING ME A LIE. I HAVE TRIED EVERY TYPE OF DIET YOU CAN IMAGINE. DIETS THAT EVEN MAKE ME PUKE EVERYTIME I EAT THE MEALS PRESCRIBED. I'M AT WITS ENDS. I HAVE A 2 YR OLD AND I'M AFRAID I WON'T BE ABLE TO INTERACT WITH HIM LIKE I WANT TO IN THE FUTURE. ANY INFO, I WILL USE TO MY ADVANTAGE, PLZZZZZZZZZZZZZZZ! :help: IT BRINGS ME TO TEARS THAT YOU WORK ALL THESE YEARS AND PUT IN SO MUCH TIME WITH YOUR EMPLOYER AND NEVER REALLY BE SICK AND WHEN YOU DO NEED THEM IT'S TRIALS AND TRIBULATION TIME. UUUUUUUGGGGGGGGHH:think

You need to actually go through the process. Find a surgeon that is on your list of approved surgeons, make an appointment, THEY will contact BCBS for you. Let the surgeon and dr.s office do the insurance dance. THEN if it's put in and denied, you can appeal also you can visit www.obesitylaw.com however, you have to start the process on your own 1st.

Best Wishes

Banded yesterday and sore as heck but very excited about my future!

Tracy