Question for BCBS FEP Band-Sleeve Folks Since 2011

[SleevedSteph 4]

I'm so glad to have found this forum! I will post this on the insurance forum also. I was banded in 2005 and did great - lost 140 pounds in 2 years and maintained until leak in 2009 and also found out I was pregnant - so no restriction and pregnancy was not a good combo and couldn't get band repaired until after baby. Gained half the weight back and then in 2011 got the band repaired (ended up just the port had to be replaced) and lost the weight back. Last October, noticed I did not have any restriction and fluro xray confirmed a leak again (where unknown). I have now gained over 40 pounds since then! I am a federal employee and had GEHA since 2005 (BCBS would not cover band at that time). Both my husband and I got the band in 2005. Early in 2012, my husband had to have his fill removed due to dilation of the esophagus (which I had never heard of before) and he started gaining weight rapidly and after consulting with the surgeon decided to convert to sleeve. I was against that but then went online and saw that it was not uncommon. Well, we were with GEHA and he was able to get band removal/conversion to sleeve approved with no problem and had it done in December and is almost back down to his lowest band weight. He loves the sleeve as the last couple of years he had so much issues with the band. Well at the same time I found out I had another leak - I also learned that my 2 yr old required intensive speech therapy which GEHA had very limited number of visits but BCBS FEP had better coverage for speech therapy so I switched to BCBS for 2013. I wasn't too concerned with me as I was hoping that I would maintain/lose weight without WLS (that didn't work!) and had always heard how great BCBS FEP was as far as approving WLS. Well, I found out that their requirements changed in 2011 and it applies to second WLS as well. I thought since my band was defective that insurance would want me to have conversion (since this is my 2nd leak and the long term results of the band has not been what the medical community thought) or at a minimum replace the band to avoid me getting to the weight I was before WLS and the health risks that come along with that. Well, I received a letter stating that band removal was approved but all the requirements must be met (for initial WLS and the additional requirements for subsequent WLS?) before conversion would be approved. There were no specifics in the letter as to what specific requirements had to be met. I tried to talk to someone at BCBS - but unlike GEHA where I could talk to the bariatric specialist - I can only talk to the customer service rep and all communication as to go through my surgeon's office. So I have asked them to find out from BCBS if EVERY requirement has to be met (morbidly obese for 2 years!, etc.) before conversion will be covered. If that is the case - will they at least replace the band now? So for those of you with BCBS FEP who have converted since 2011 - any suggestions you could give me would be greatly appreciated! I found a great appeal letter from "Britt" but it was before the requirements had changed for subsequent WLS. Thanks!!!

[chinamama 104]

Well I converted on the 29th. We have fepblue basic. Yes they made me jump thru all the hoops, 1 psy visit, 3 nut, 3 visits w surgeon for supervised medical wt loss, referral from pcp, sleep dr. I had a denial and a peer to peer. Something was messed up with nut visit finally approved 2 weeks ago today. I could have had it removed at anytime it was the sleeve that was the holdup.

[tlah 40]

They approved me in 4 days. Fepblue basic. I used weight watchers 6 weeks from starting to surgery date I onky had nausea but its been great followed my pre op to the t. And I believe that's why ni complications post op day 5 I'm doing 2 miles in the morning and 1 mile at night. No gas pains at all. Regularly having bowel movements

[SleevedSteph 4]

Thank you, ladies, for the reply! Were you required to show morbid obesity for most recent 2 years? I don't understand why ins would require that for defective devise/subsequent surgery. Also, my PCP said that BCBS is looking for 10% weight loss during supervised diet (I have gained!). How much did ya'll have to lose during the 3 month supvd diet? Chinamama - what is a peer-to-peer review? tlah - great job on the exercise!

[tlah 40]

It all depends on your insurance coordinator at your doctors office believe me they can work wonders. From getting my last unfilled for Lapland issues to getting my date was six weeks. I was 214 when I got unfilled. I was 200 at surgery on may 2. They accepted weight watchers as the supervise diet. And it wasn't 90 days as long as I attended feb. march and April. My doctors office contacted them the Friday after my first April meeting on the Thursday night. By Tuesday I was approved and by Friday had letter in hand from bobs. My doctors office was so confident I had my three nut apps. And psych done before approval. Any help you need let me know also I have basic not standard. Please remember follow the pre op. it is what helped my surgery move faster along without complications and driving the day after I got out of hospital the staff said to me you must of followed the rules because of how I recovered. There two women on my floor who cheated during pre op and were doing terrible they were in so much pain. Surery was longer liver still had slime on it

[Kami63 215]

I'm at the same point with BCBS. I found out today that they approved the lap and removal in two days but they want a lot of appointments to approve the revision to the sleeve. They want proof I have been overweight for two years, a nutrition appointment and a psych appointment. I am lucky they didn't say that I need 3 months supervised diet. So I will get to work! Good luck to you

[chinamama 104]

I'm at the same point with BCBS. I found out today that they approved the lap and removal in two days but they want a lot of appointments to approve the revision to the sleeve. They want proof I have been overweight for two years' date=' a nutrition appointment and a psych appointment. I am lucky they didn't say that I need 3 months supervised diet. So I will get to work! Good luck to you <img src='http://www.bariatricpal.com/public/style_emoticons/<#EMO_DIR#>/smile.png' class='bbc_emoticon' alt='' />[/quote']

Even though they are not requiring the 3 month I would go in and see your surgeon or pcp. Make sure you go in every month, take 3 days sample menu and make them weigh and chart it all. I did it with the NUT, but for some reason they wanted to see it with the dr also.

Good luck

[chinamama 104]

A peer to peer is when you have a denial. The surgeons office and the medical director at the insurance company have a conversation about your case. The denial can be overturned or upheld. In my case they wanted 3 months medically supervised weight loss. Dr just documented we had met and had discussed the surgery and diet aspects and weighed me. I orig. gained and then lost 3-4 lbs last visit.

[tlah 40]

I'm at the same point with BCBS. I found out today that they approved the lap and removal in two days but they want a lot of appointments to approve the revision to the sleeve. They want proof I have been overweight for two years' date=' a nutrition appointment and a psych appointment. I am lucky they didn't say that I need 3 months supervised diet. So I will get to work! Good luck to you [/quote']

I did weight watchers 3 visit with my doctor I was scheduled in 6 weeks I have basic on the federal