Please help - Insurance BC/BS of AL

[PmPruneda 0]

I have BC/BS of AL...I have done everything that was required but they keep saying I have not dieted for 6 months, I have done this with a Doctor supervising, but they keep saying it dosen't qualify but they also won't tell me what does qualify...I have tried going to the Ins Comm. but the problem is I live in WA and they are in AL...so WA is saying they can't help becasue the insurance is in AL and AL won't help becasue I live in WA...

Any Suggestions???

[JUSTTIRED 0]

So sorry to hear of your troubles, I too am fighting BC/BS but of IL....I got declined for same issue, even though I went to my PCP for 6 months and he filled out the form the Surgeons office provided. Seems like it should be illigal for them to discriminate in this way. Good luck. My Drs office if going to add more notes to the forms to see if that will help.

[kajunlady38 0]

do you have bcbs ppo?

[JUSTTIRED 0]

yes i do...and it stinks...

[kajunlady38 0]

oooo man! i'm finished with all my pre surgery stuff...just waitng on the dr to send my paperwork to the insurance to see if im going to get approved or denied because i didnt go through a 6 month diet thingy...but they did say it seems as though its 1 of the best insurances they've seen..sooooo idk

[JUSTTIRED 0]

kajun

Make sure that your drs office makes sure that there is good detail in everything they send in. My drs office didn't do that and now i'm going to have to fight to get it done.

Best of luck.!!!

[kajunlady38 0]

awww im so sorry to hear that :[ such an aggrevating process! have you heard of anyone with a blue cross ppo that hasnt had to go through the 6 month thing? i also wish you better luck

[JUSTTIRED 0]

not sure a/b that. I believe bc/bs can be different depending on the plan/your employers choices etc. So they all are diff. Don't give up...keep fighting

[kajunlady38 0]

thank you so much....and also yourself stay strong it will happen !!

[wmorris 0]

I got approved by BC/BS of Alabama. I had to do 7 months in my program. They were very strict by what had to be in every months weigh in session. A statement by the Doc documenting that I chewed 20-30 times, put my spoon down between each bite, parked my car in the far parking lot, etc. etc. My Lap Band team out of Pensacola, fl were very good and made sure my documentation was perfect. It had to be done for each session without skipping a month. Good luck

Ps The insurence companies are so shortsighted.... they don't relize with this procedure they won't have to pay for heart operations or other more costly procedures or meds in the future.

[TSB 1]

do you have bcbs ppo?

I have Anthem BC/BS. Our plan is called a POS (point of service) Don't know how that differs from PPO or HMO. I am in the early stages of this process. My doctor did a referral in Jan. and I will see the surgeon for the 1st time on March 13. Because I have read about such a variety of experiences w/ BC/BS I did a little investigating in regards to the policy I have through my employer. What I found is copied below. The caveat is that this is specific to the policy my employer subscribes to. If you go to the Anthem site (http://www.anthem.com/ ) and look up your state, you may be able to find out what the policy is re: WLS based upon the plan you subscribe to.

Medical Policy

Subject:Surgery for Clinically Severe ObesityPolicy #: SURG.00024Current Effective Date: 04/16/2008Status:RevisedLast Review Date: 02/21/2008

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 document addresses those procedures.

Policy Statement

Medically Necessary:

Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example the Lap-Band® System or the REALIZE™ Adjustable Gastric Band), 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 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), 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, band hermiation, or pouch enlargement due to vomiting.

Not Medically Necessary:

Stretching of a stomach pouch formed by a previous gastric bypass/restrictive surgery, due to the patient overeating, does not constitute a surgical complication and the revision of this condition is considered not medically necessary.

Edited March 5, 2009 by TSB
Typos

[Lisaannclark 0]

I have Bc/Bs of Tenn and the requirements are diff for each plan. mines wants me to loose 10% of my total body weight. Others that I heard of was 6 months supervised diet but they do not include the 1st month as a full months so it si REALLY 7 months. Also on the denials.. The DR's office should help you find out why it was denied.. you should not have to be going thru this process alone.. they are getting paid for the surg so they are in the business to help you so that they can get their money.

I am on the 10% and have 10 more lbs to go.. I have done everything else upto this point. Me and my 2 other firends are going it together.. it helps because when one get a denial and finds out why, the other can make sure they dont get the same denial..

P.S. Appeals can be submitted by the DR'd office OR by yourself.. I have been told that the chances of you getting an appeal overturned and approved is better then the DR's offcie..

Keep up the good work and STAY STRONG! this is an illness and the health insurance companies are starting to see that, just not as fast as I would like them to is all..

[wheverson 0]

I have highmark PPO (blue cross/blue shield), I just called my ins today and they said my surgery has been approved (1 day after dr. sent it in). I HAD to do thhe 6 month supervised diet. My dr. office handled everything, told me all the appoints, etc. I had to do and once I did everything the approval was a snap. Good luck to you

[pickles123 0]

Thank you all. I have searched and the final answer side for Athem that TSB posted seemed to give me most of my answers.

Thanks so much you guys. I have hope now and can start the process. I will keep you all posted.

Anyone that can give me any help I can sure use it.

Thanks so much.

Pickles123

[munkee'smommy 0]

I have BC/BS. knowing what little i do, (u'rs is different from mine) but I think that you need a 7 month consecutive diet that is verified monthly by a doc. they say 6, but for some reason the 1st month doesn't count. I hope this helps. I am lucky as my group # doesn't require the diet, but they say i have to pay 50% of the surgery. Did they tell you that too?