BCBS of Alabama - My Journey

[andyisbanned 1]

To get approved, you have some hoops to jump thur. I started with a seminar on the Lap-Band and learned as much as I could on-line. At the seminar, Dr. Britt & Dr. Groves along with their staff provided a very informative hour. They stay afterwards for an hour or two for Q&A.

BCBS of AL began approving the Lap-Band surgery in April 2007. It may vary according to your policy as to what or how to qualify. My policy will only cover 80% of the surgery but 100% of any follow up for 1 year. I will have to pay about $400.00 prior to surgery.

Here is my experience to get approved with BCBS:

1. You must have a BMI over 40 without any co-morbidites or over 35 with at least 2 of 3 co-morbidites. The co-morbidites are sleep Apnea, High Blood Pressure, & Diabetes. My BMI is over 40 and I have Severe Obstructive sleep Apnea (OSA) and High Blood Pressure. Due to my OSA, I have a trach.

2. You must have maintained a BMI of 35 with co-morbidites or over 40 for the last 3 years. This is will be checked and verified by your surgeon & BCBS thur copies of your medical records you must have submitted by your doctors to the surgeons office. I received a application packet at the seminar and it had the forms to send to my doctors to request the release of a copy of my records to my surgeon. I was able to have my sleep doctor, my ENT, and my family doctor submit copies of my medical records for the last 5 years which I think helped. Any of the doctors you have visited in the last 5 years counts. The insurance is looking to verify you BMI thur your recorded weight & height records from the various doctors.

3. If you meet 1 & 2, you must now complete at your expense a 6 month doctor directed diet with your family physician. During the diet, you must maintain a exercise and food journal to document your success or failure of the diet. This stage will require 7 monthly visits, scheduled at least 30 days apart with your family doctor. This is key as BCBS requires at least 30 days between each visit or it does not count. One day to soon and it will result in failure for approval. Your physician will be required to fill out a paper each month to provide to your surgeon for submission to BCBS. My surgeon provided the form and my family doctor just made copies each month and gave me the original to send to my surgeon. It cost me about $500 to complete this phase. I finished in December 2007. My family doctor knew why I wished to complete this diet program and was very supportive and understanding. My sleep doctor and ENT want me to get this surgery to help with my OSA.

4. Once complete with the diet, your surgeon can submit your paperwork to BCBS. BCBS will then require a consult with a physical therapist and a nutritionist. These consult visits are to teach you the exercise and diet plans you must follow prior to and after the surgery. I spent an hour showing I could do the exercises with the PT. I then went and spent the next hour learning how & what to eat. I am putting it to practice now. They say it takes 40 days to make or break a habit. I have learned that some people are not required to complete this step. However, some have to complete a psychiatric evaluation and/or a sleep study. It just depends on your policy.

5. After the consults, your surgeon will submit the paperwork with the reports from PT and nutritionist. Now is the time to sit back and wait on BCBS. My approval only took an hour as the surgeon's office file on-line.

Just a note here: My surgeon tells me that if BCBS rejects your request for approval, BCBS will tell you why. One patient of my surgeon was rejected because he went to his last diet visit on the 24th of the month. All of his other visits had been on the 26th of each month. This patient had to return to his family doctor for the last visit, then resubmit his paperwork. By the way, he was approved. It just shows how critical it is to keep the apponitments 30 days apart on the diet visits and to work closely with your doctors & surgeon.

6. With approval, I had to complete a pre-op training class (about an hour long) with the surgeon's staff, then have a pre-op physical with my surgeon. Then my date was set. I will have surgery on February 14th.

7. Final step is to get the surgery and start life a new.

I am using Dr. Britt of Marshall Surgical group from Guntersville. They provide a free seminar monthly at the Madison Surgery Center on Lanier Road in Madison, Alabama. They also provide free seminars on the Lap-Band at Marshall Medical North & Marshall Medical South. You can check their website at http://www.samc.stirsite.com/home.html or at the hospital website Marshall Medical Centers. Dr. Britt & Dr. Groves have surgery rights at the Madison Surgery center, Crestwood in Huntsville, Marshall Medical North in Guntersville, and Marshall Medical South in Boaz.

I hope this helps anyone who is looking at the Lap-Band surgery and has BCBS of AL. BCBS Federal is different than the standard BCBS of AL. You can find several on the forums with experience with the Federal version of BCBS.

[Savedbygrace 11]

Thanks for sharing your journey so far. I am a little upset to read from you and one other person that BCBS requires 30 days bw each visit. My policy states that I can go to a nutritionist for 7 visits and see my MD 3 times within that 6 months. I chose that route because in the long run, it was cheaper and I knew I needed the nutrionist more than just seeing my doctor every month. Well my nutritionist works closely with the physicians here in Huntsville (but I'm using a surgeon in B'ham..not that it matters lol) BUT... I started this on 8/22/07. In December, she took 2 weeks off so she moved my appt to 12/19. I questioned her about this and was told as long as we end around the same day of the month, it will be fine. If I have to start this ALL over... I will be devistated!!!!!!!!!!!!!!!!!!!!!!!!!!

My physician appts were more than 30 days apart but only 3 of them, as required by BCBS. Because the short month wasn't my last month (that being 2/25) I wonder if I will have to start all over or if I can just add one more month - if I HAVE to?? Any ideas? I guess I can call BC and ask. GGRRRRRR

[bamafever 0]

I am also using Dr. Britt. I was just approved on Friday! They make it easy with the forms that they provide for you to take your doctor. Hang in there.

[andyisbanned 1]

Bama:

Good luck on your surgery. Dr. Britt and staff are wonderful. I was banded on 2/14/2008 at Marshall Medical North by Dr. Britt. amy is great and the pre-op class with her is very informative. Elizabeth will actually schedule your surgery. If you have started you pre-op diet, then I would think you should be able to have surgery next week. Keep us informed.