Getting Closer to submitting pw...fear of rejection has kicked in!

[reachbree 140]

I've completed everything except the Upper Endoscopy which for whatever reason is taking 3 months to schedule (I don't get it, I really don't get it).

My last NUT apt is coming up. this week. I have learned that BLUE Sheild CA no longer requires 6 months of supervised WL diet so I have done 3. My Surgeons office is STILL insisting its still 6 months with Blue but say I can take my chances and they will submit after 3, however to prepare for a decline

Trying not to think negatively byt Im so borderline on that BMI and have no medical issues at all...I have/had pcos but my OBG took me off of Metformin after my son came 2 yrs ago and said the cyst on my ovaries are disappearing..somehow, plus my cycles magically straightened themselves out after baby came. Anywho I don't think insurance will accept that as a medical problem now.

Has anyone else been accepted/declined in my situation? Would love to hear your story, short or long

[2goldengirl 2,076]

As I remember, you are Blue Shield H M O, correct? I had to fight to recognize that Blue Shield had changed their requirements. Once I did, I sailed through. Zero months of weigh ins. Starting BMI of 39. sleep apnea, only diagnosed during the preop process. Approved. Done.

When you say you're on the borderline with BMI, do you mean you're somewhere between 35 and 40, or 40 or above?

It doesn't matter if you're 40.1 or 50 - if you're over 40 BMI, you don't need comorbidities to be approved. I believe I've said before, call Blue Shield and ask to speak with a Supervisor. They have people in member Services who don't take the time to review the policy when members (or providers) call and go by cheat sheets they keep on their desk. You know what the policy is, you've reviewed it online. Demand that your medical group, your surgeons office, whomever, abide by the current policy. Period.

Now, find something else to worry about

[liposuction68 178]

just do the six months i was denied. i had the band put in in 2006 it was a breeze my bmi was lower than 40 i had no comorbities ( ithink he used my lower back problems) so moving forward to now 10 years later i need to get a revision to sleeve. i pretty much argued with my coordinator when she said i have to do six months nutrition visits. i would not accept my insurance requirements had changed so they submitted it with out that and i was denied this was in february. i had a tentative date for surgery March 1 soooo today was my clearance i got my psyche eval done chest xray ekg blood work and Yes i have six nutrition visits. they used three that i had before i even came in to discuss a revision (i was still getting fills and unfills fills unfills) and three since january when i actually did go in to discuss revision. so my date is now April 5 they should be sending it to insurance again hopefully by tomorrow or wednesday as i made my PC that did my clearance /ekg fax it to them before i left the office...

So try using the visits that you already had along with what you have to date and see if that works. you wanted to hear good or bad and this was bad im even thinking about going to Mexico if i dont get approval. i also put a call in to LINDSTROM OBESITY ADVOCATES and got a free consult when Kelley Called me back. Basically they are a lawfirm experienced in getting a denial reversed. the phone number 1-619-656-5251. Check out their website out too..

i too have bcbs empire UNH

good luck keep us posted..

[reachbree 140]

Thanks Liposuction68, sounds like you have been through it. Fingers crossed everything goes smooth this time around!!

2 goldengirl...Yes, its me again! I had spoken with BS/BC CA rep and she laid it straight that they no longer have that 6 mo requirement and she pretty much said the same as you regarding other reps not looking into the updated policy.. Will definitely ask for a manager next time, maybe they have another suggestion as far as getting my surgeons office updated on that policy. Nonetheless, my surgeons office said they would go ahead and submit paperwork when i'm ready, just wish they would stop looking at me like i'm making this stuff up.

[lolarose13 147]

Hi @@reachbree! Crossing fingers for you!

I also have Blue Shield of CA and I'm so nervous! I'm barely 35 BMI, with PCOS, high cholesterol and insulin resistance and I'm trying to get a revision from lap-band to sleeve. I'm having so many problems with the Lapband but I'm super fearful they are going to denied the approval because my borderline BMI

Sent from my iPhone using the BariatricPal App

[2goldengirl 2,076]

Hi @@reachbree! Crossing fingers for you!

I also have Blue Shield of CA and I'm so nervous! I'm barely 35 BMI, with PCOS, high cholesterol and insulin resistance and I'm trying to get a revision from lap-band to sleeve. I'm having so many problems with the Lapband but I'm super fearful they are going to denied the approval because my borderline BMI

Sent from my iPhone using the BariatricPal App

@@lolarose13

From Blue Shield's policy concerning revision:

Revision Bariatric Surgery

Revision surgery to address perioperative or late complications of a bariatric procedure may be considered medically necessary. These include, but are not limited to:

• Staple-line failure

• Obstruction

• Stricture

• Nonabsorption resulting in hypoglycemia or malnutrition

• Weight loss of 20% or more below ideal body weight

• Slippage that cannot be corrected with manipulation or adjustment (see Policy Guidelines Section)

Revision of a primary bariatric procedure that has failed due to dilation of the gastric pouch or dilation proximal to an adjustable gastric band (documented by upper gastrointestinal examination or endoscopy) may be considered medically necessary when both of the following are met:

• If the initial procedure was successful in inducing weight loss prior to pouch dilation

• The patient has been compliant with a prescribed nutrition and exercise program.

So it isn't your BMI in the case of revision, it's these guidelines I listed here. The key for your surgeon will be documenting the issues you've been having with your band, and your history of adhering to postop guidelines since you got it. Good luck!

[2goldengirl 2,076]

@@liposuction68, the guildelines are different in California than in New York. The guidelines we are all writing about are specific to CA H M O coverage.