Sorry but yes I have another insurance question

[Ellisa 6]

Hang in there! Try not to let it get to you. It got to me, big time I gained 5 lbs from the time I went in for my original consult until I had my pre op appointment! Don't do that... stay in preparation mode, if you can.

I'll keep checking on you.

[kaninag 35]

I guess God is telling me not to have this surgery. I finally got in touch with a case manager at BCBS....ok she said she will try to rush the approval and hopefully have a decision by tomorrow...no guarantee but thats better than nothing...so I called the doctors office and now he is out of town until 1/7.....so I wouldnt be able to have it this year anyway....then I asked the girl about my insurance changing and she said that we would have to REFILE EVERYTHING!!!!! ARE YOU KIDDING ME!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! I couldnt believe....so I have wasted all this time and energy only to be slapped in the freaking face!!!!! I have to go thru all this crap again....my new insure empire blue goes into effect 1/1 but she said she would see if they would go ahead and let her file a claim...if so she would send all the info tomorrow.....this is AWFUL!!!!!(

[Ellisa 6]

Sometimes, I repeat sometimes, when insurance is provided by the employer they will negotiate with the new insurance company to keep the same benefits for at least a transitional period. It's possible, if there's no exclusion on your new policy, that they will accept the approval of your current insurance. Won't hurt to work that angle, it might fast track your approval. Government agencies and union companies seem to care more about this sort of thing, in my experience. So what I'm saying is, it's possible your approval with your current company could be part of the deal with the new one, if your HR department is willing to go to bat for you.

Hugs.

[kaninag 35]

No-I have to refile.....which SUX I REPEAT SUX! I told my husband I give up....I'm gonna go thru all this and their gonna DENY me...I mean cuz honestly I'm not that sick.....But at the same rate....I dont wanna get sick bc I keep getting fatter you know.......oh well EMPIRE BLUE HERE I COME!

[jenncore 0]

As frustrating as this is, please don't give up. You have done so much work to get this far. Call the insurance co. and the surgeon's office everyday until you hear something. It took my insurance co. about 5 weeks for approval and when they finally approved me it was the bypass not the lapband. I was freaking out. I didn't give up though because I busted my a** getting everything together and ready for the big day. Please hang in there!!! I really wish you the best and have my fingers crossed that everything will work out for you.

Jenn

[Chris61 0]

Kaninag - I would just call your doctors office and have them resubmit everything that they had sent to the other insurance company. I would also call your human resources office and/or insurance broker and talk to them about what is going on and see if they can help push it through. You might be sureprised that it is the same people you are dealing with now. I know it is tuff. We had problems with UHC and getting my wife approved but we kept on them and sent another letter from another doctor and she was approved within 15 minutes of them getting the fax letter from the doctor. Now we are having problems with them paying for the fills. Funny thing is they have paid for 2 sets of fills from the hosp. but nothing to the doctor yet. We have been working it both sides and hope to get an answer soon. If you have any other questions just ask away. Also keep in mind that most states say that they must answer you within 30 days of a request. I know some people here has said it takes longer.

Chris

[Ellisa 6]

Kaninag,

I'm sorry to hear that, but don't give up. If you meet the qualifications and there's no exclusion on your policy it will be approved.

Chris,

Go Bucks!!!

Also, my insurance BC/BS does not pay for fills. So only the ones included with my surgery are covered. I think I do get a reduced rate with in network facilities, but that's it.

[kaninag 35]

Thanks, I will call the doctors office after the holidays. I hear that Empire Blue is somewhat easier to deal with...which makes no sense to me as they are still BCBS. I hope now to HOPEFULLY have my surgery the end of january....so......here we go again

Anyway, Thanks a lot for your support!!!!!!!! HAPPY NEW YEAR!!!!!!!!!

[kaninag 35]

Ok, I can finally log onto my new EmpireBlue insurance stuff and I went under their medical policies and was a little surprised...NOWHERE does it say that you have to have had a BMI >35 for x amount of years....Regular BCBS policy does....This helps me (I think/hope) cuz CURRENTLY my BMI is 43 it has been over 35 for the last 3 years but not over 40...is this good...somebody please tell me if it not in their medical policy then it doesnt apply!!!??????

[4jin 0]

Ok, I can finally log onto my new EmpireBlue insurance stuff and I went under their medical policies and was a little surprised...NOWHERE does it say that you have to have had a BMI >35 for x amount of years....Regular BCBS policy does....This helps me (I think/hope) cuz CURRENTLY my BMI is 43 it has been over 35 for the last 3 years but not over 40...is this good...somebody please tell me if it not in their medical policy then it doesnt apply!!!??????

Kaninag,

I have BCBS. My BMI is 43 as well. I have no co-morbidities. I actually worked on gaining weight so I could surpass their mindfoundling required BMI of 40+. (Did a bit too good at gaining ha!)

The general requirements lists:

A. Deemed Medically Necessary by your PCP

Then Meet requirements of:

1. BMI 40+

or if BMI lower should be at least 35 with TWO co-morbidities

the other requirements are the usual....

psych eval

nutritionist eval

ekg

echo

physical exam

lab blood works

informational seminar

consultation with surgeon

I have a link but it is to the BCBS of Georgia....you might want to do a google search under bcbs for your state and check under their general guidelines and requirements which is the criteria they utilize when evaluating for approval process.

[kaninag 35]

Thanks for the info. My case has been started with EmpireBlue..my doctors office has never dealt with them before so she really didnt know what to do...she called 1/2 and started a case on me and the nurse was supposed to call her back with a fax number so that they could fax my clinical info...they never called so i called.... got a fax number, nurses name and extension my doctors office was faxing my info TODAY!!!!!

[4jin 0]

Thanks for the info. My case has been started with EmpireBlue..my doctors office has never dealt with them before so she really didnt know what to do...she called 1/2 and started a case on me and the nurse was supposed to call her back with a fax number so that they could fax my clinical info...they never called so i called.... got a fax number, nurses name and extension my doctors office was faxing my info TODAY!!!!!

Good luck to you!!!!

I am in the waiting lingo.......

[kaninag 35]

4Jin,

Question....so if you're BMI is greater than 40 NOW even though it hasnt been for the last 3 years...they will approve you? See, BCBS gave me a hard time and said it had to be above 40 for the last 3 years or greater than 35 with 2 co-morbidities....but thanksfully EmpireBlue seems to not have a time frame requirement...

[4jin 0]

4Jin,

Question....so if you're BMI is greater than 40 NOW even though it hasnt been for the last 3 years...they will approve you? See, BCBS gave me a hard time and said it had to be above 40 for the last 3 years or greater than 35 with 2 co-morbidities....but thanksfully EmpireBlue seems to not have a time frame requirement...

Kaninag,

See it all depends when your paperwork was submitted. Effective 1/1/2008 they have changed their requirements.

This is the new requirements if your information has been submitted on or after 1/1/2008:

is considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL 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
   
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.

Surgical repair following gastric bypass and gastric restrictive procedures is considered medically necessary when there is documentation of a surgical complication related to the original surgery, such as a fistula, obstruction, erosion, disruption/leakage of a suture/staple line.

My information was submitted before 1/1/2008. For my decision they must follow the guidelines/requirements before the changes were made.

The only change they made is as you stated they added a medically supervised diet. However, even if they do require it for me I have it. I placed my own self on one lost from January 2007 to July 2007 65 lbs..but gained it back from July to October 2007. At that time I decided I needed medical help for the long term not just pills and diets that make you want to scream...

I am still waiting for approval...don't get me wrong...but this is the info I was given by BCBS themselves. (then again we know they can be )

[kaninag 35]

When I submitted my paperwork in dec they required a 6 mo medically supervised diet...so i think that is still the same