Blue Cross of California

ReneBean · September 28, 2005

Hello Girls and Boys...

Has ANYONE ever been approved by BC/BS of CA for this procedure??

I kinda figured with a BMI of 59.7 I would be a no-brainer - however, I received a denial for my pre-approval with this text:

"There is insufficient medical literature to determine the safety, superiority or equivalency and long term efficacy of this procedure in comparative trials with gastric bypass or duodenal switch. For these reasons it is considered investigational. The Blue Cross of California Medical Policy for Surgery for Clinically Severe Obesity, which is based on published peer reviewed evidence based medical literature, was used in making this determination."

So, what gives? What does "Investigational" mean? Any help would be appreciated. Obviously, I will appeal since I consider this to be the highest for of the brown stuff from a male cow. Any contributions from the wise and experienced would be appreciated.

La_madam · September 28, 2005

I had BC of California and was denied, I had a BMI of 42 and no co- morbitities, I was a healthy fat person basically. I'm happy I chose MX, or I'd most likely stil lbefighting with them and still 95 lbs heavier if not more

MelissaE1979 · September 28, 2005

I was told by the insurance coordinator at my dr office that Blue Cross has started approving lap band as of May 25, 2005 when billed under CPT code# 43843. According to her, this is a new code.

ReneBean · September 28, 2005

Thank fortune that I seem to be in a permanent maintenance mode - or I, too, would be concerned about gaining 95 lbs... But seriously, has anybody ever been covered by BC/BS of California? Or should I just go for financing, now....

Alexandra · September 28, 2005

Renebean, this is exactly what I was up against and managed to beat more than two years ago. See the thread called Just Starting to Explore Options in the Insurance forum for a discussion of how to appeal.

Personally I think you should appeal even if there's little chance of winning. You can seek financing while your appeal is being considered; there's nothing to lose by starting the appeal process. And you just might help the next person down the line.

ReneBean · September 28, 2005

Oh, yes - I will definitely make the appeal - and I guess I don't have to wait to at least investigate financing. (uh-duh). Of course, I can't afford to make any more payments right now - so I don't know why I am bothering - but I will investigate all the options.

It's not like this was unexpected - but I had managed to hope that somehow, against the odds, insurance would look at my 59.7 BMI and think - "well, if she thinks it will work for her - let's give her a shot..." Talk about a vivid fantasy life...

Anyway, my coordinator at LapBand Solutions is reviewing the letter with her supervisor and I have requested a copy of the insurance requirements for "Investigational" procedures as per the offer in the denial letter and I have a request for review in with ObesityLaw.com.

NJChick · September 28, 2005

Beanie, insurance companies will do this in the hopes that you will not appeal it. Lots of people who get denied will just close the book and say oh well, I tried.

One thing I've picked up from talking to you is that you will not take this crap.

Come on Hurricane Irene !!!!

ReneBean · September 28, 2005

All right.

I have called Blue Cross for a copy of their policy on "Investigational Procedures."

I have faxed my denial letter to my coordinator at Lap Band Solutions.

I have sent an e-mail to Don Mills at Inamed to see if he has any current research references that I can add to the ones in Alex's letter from the sticky thread.

I have sent inquiries to both ObesityLaw.com and BandedLawyer.com to see about help for an appeal.

The wind is kicking up...

NJChick · September 29, 2005

Hold on to your britches BCBS !!!!

GeezerSue · September 30, 2005

Blue Cross of California (not BC/BS) just changed their policy, based on new research that show that banded people with BMI's over 50 generally do not lose enough weight to get out of the MO category and get rid of the comorbidities that are so badly impacting their lives.

I think I posted about this somewhere (but I guess not here.) Wherever it was, everyone wanted to argue about it. But after looking at large groups on follow-up, there were not enough people who started with a BMI's of over 50 and got to BMI's under 40.

Of course, the stats, two or three years out are the same for RnY. But they GET to a lower weight before the weight rebounds. So they can blame the RnY patients for the weight regain. The study I read "blamed" the band.

I don't want to rain all over your parade, but even if you beat the "experimental" denial (which I think you have a good chance of doing), you may still have THIS hurdle to deal with.

ReneBean · September 30, 2005

Thanks for the info, Sue. At Least I have something to go on as to why in the heck they would not approve me. The letter I got did sound like they would approve me for the Gastric Mutilation...

I guess I will just have to fight that based on the fact that either by God's Plan, or by a Million Years of Evolution, the body is a finely tuned biological machine - and I do not believe in causing permanent damage to the system.

Besides - Even IF I only lost 50-60 lbs - my health risks would decrease dramatically.

Anyway, thanks for the info, Sue.

GeezerSue · September 30, 2005

I think yo should appeal the denial they gave you. You MIGHT slip in between policy changes!

Sue

:::currently preparing to battle BC re approval for DS:::

ReneBean · September 30, 2005

Well, it looks like it IS my BMI that is stopping me. Damn.

For anybody else working with Blue Cross of CA - here is the link to their policies:

Go to this link and then go to the “View Alphabetically” link, scroll down a bit and “Adjustable Gastric Banding” is listed there. Their new policy is shown here as well as their requirements before they offer coverage. http://medpolicy.bluecrossca.com/

GeezerSue · September 30, 2005

Far be it from me to be argumentative (that's a joke), but right now, it's an "experimental/investigational" denial. And that can be overturned, because it's hogwash.

ReneBean · October 1, 2005

Argue away - I love a good arguement.... But I won't fight on this. I will still make my appeal - but I guess I am going to have to have an attorney do it. *Sigh*. It's only money.

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