airwayman

I know I've railed about BCBS in previous posts. I said the first word they learn is NO!! But I've changed my tune. I started this journey in January and FINALLY completed all the requirements last Thurs. when the Dr's ins. guru faxed my folder to BCBSNC. That was on Thursday, midday. Saturday, two days later, I get a snail mail, not a fax, not a phone call, not a FedEx overnite letter, a snail mail from BCBS APPROVING my request and wishing me good luck. Must be some kind of record. JB

How can Splenda, Equal or any other calorie free sweetner contribute to weight gain? I'm sure many people don't tolerate the chemicals that make up these sweetners, that's another issue. But gaining weight from drinking sugar free sodas? How can you gain weight if there's no calorie content? Point me to the studies, please.

I am waiting for a surgery date, having finished all the studies, including a NEW sleep study. I've had sleep apnea for 9 years and have been using the machine every night. Yes, it is a pain in the ass but it is a necessary evil for those of us who have sleep apnea. I hope someday to get off the machine, like Jack did, but for now, all I got out of the sleep study was a new machine and an updated pressure setting. Trust me, if you have the sleep study, and they say you have sleep apnea, you NEED a machine and you WILL feel better. It shouldn't have anything to do with your surgery scheduling. The best thing that could happen to you if you have sleep apnea is to lose weight and someday realize you wasted your money on the machine. Rent a boat and use it for an anchor.

Mandy, there's a perfectly good explanation for this, the hospital didn't have a Porsche payment and alimony due that week. :phanvan JB

I have not been banded yet, nor has the Dr's. office received approval from BCBS (it is to be faxed today) so I haven't "been there, done that." But I don't understand how this happens. What can be "iffy?" If they paid the doctor, then you must have met all their requirements. What possible reason could they give for not paying the hospital? Sounds like to me you're home free. Good luck! JB

Jason, what's the problem with protein??? meat? eggs? cheese? I love that stuff!! Thought all men loved protein. Guess not, huh? What are you eating that is "evil?" What Protein Shake are you drinking that is not too bad? Good luck. JB

Hi Free. First, I'm no expert....I haven't been banded yet. But, I read a lot. Two things came to mind when I read your post. First, I've never heard anyone say a 4cc band holds more than 4cc but the doctor surely knows what he's talking about. Other bandits with experience will surely respond to this post. But secondly, 25 lbs. in almost 9 months? That's probably why the doctor put so much in your band. You apparently didn't have enough restriction and were eating too much. Look at the ticker factors for all these people on this forum. Yes, they're all different but 25 lbs. in almost 9 months is surely on the low side. As to your worries about erosion, a member posted that her doctor said in 1000 bands he had not had one erosion. I asked my doctor if that was possible, he said yes it was. He said erosion does occur but the risk is very, very small. JB

This is absolutely ridiculous!! This is no way to treat someone who is trying to go by the rules and learn what must be done to qualify for an approved medical procedure. If I were you, I'd call the NY state insurance commission and complain. In contrast, I called BCBS NC because I had heard a rumor that they were on the cusp of changing their policy for gastric banding. The first person I spoke with was a complete idiot. She was more than that but idiot will do on this forum. I quickly begged out, hung up and called back later. The second lady was fabulous. She said she had heard there was a change in the policy but was unfamiliar so, together, online, she walked me through the clicks to get to the .pdf file titled BCBS of North Carolina Corporate Medical Policy for Surgery for Morbid Obesity. Together, we read the changes, which moved gastric banding from "investigational" (read not covered) to the approved procedure area. The policy also states the requirements and the exclusions for gastric banding surgery. I was able to print this out and in ten minutes I had the approved procedure in my fat little hand. I have now fullfilled all the requirements and am waiting for the Dr's office to call with ins. approval. They said it normally takes up to two weeks. Some have been coming back approved in one week or less. In your case, I recommend you work through your Dr's. insurance person. He surely has one or more people who deal with Empire BCBS all the time and know the ropes. Good luck, my friend. JB

So, your Dr's gals are Kim and Dawn? Weird, I'm in NC and you're in NY? Reminds me of the joke about the two guys who just happen to be sitting next to each other in a bar in Miami. They get to talking and find out they're both from Chicago, both live on the South side, both live at 314 Elm street and are BOTH married to a woman named Elvira. One says "Well how about that!!! We's husband-in-laws!!!" As regards your pulmonologist's lack of concern, that reminds me of the time we were having a house built. The shutters came prepainted and in boxes so we didn't open them to see what they looked like. Later in the day I went out to the project and all the shutters on the top of the house were black and the ones on the bottom were brown....obviously there was a mix up in delivery The foreman drove up and I was mad!! I asked him why ANYONE would put those shutters on when they knew they were the wrong color!!! He calmly looked at me and said "hey, it ain't their house." The shutters were fixed and life goes on but I never forgot that lesson....no one really cares as much about you as you do. You are your own Captain. Steer your own ship, don't let others push you off course. I have the upmost respect for doctors and nurses but, "hey, it ain't their body." Good luck, my friend. JB

Well, let's see....I filled out ten pages of information, I've been to the required seminar, met with the psyco lady, the exercise specialist and the nutritionist. My PCP set me up for the chest X-ray, the lab drew 10 (yes 10) viles of blood for all the required blood tests. I met with the Dr's. PA, then the doctor. I met with the office manager who went over my ins. policy and expected out-of-pocket expenses. Then, let's see, I had the H. palori(?) breath test, then I went to the radiologist for a barium swallow test. All of this took...oh, two months, maybe longer. Next, I'm to call Kim the Dr's. ins. lady if I haven't heard from her by this coming Monday. She is going over my records and will talk to BCBS (she's already had an initial call w/ them) then it goes back to Dr. V, who looks over everything, if he is satisfied, it goes to Dawn, his nurse, for surgery scheduling which normally takes about a month. Before surgery I will be required to attend his pre-surgery class where they go over everything related to the surgery and give you the details of the required two week liquid diet. I'm almost there. JB

Kindred, as you can see from these posts, all BCBSes operate independently and have their own corporate policies for morbid obesity. I live in NC, I printed out the corporate policy last year, as I had done the last three years, and "gastic banding" was labeled "investigational" which is to say it's not approved (investigational procedures are not approved). Then I heard rumblings and, in Feb, the policy was changed TO INCLUDE GASTRIC BANDING!!!! Now, this is NC....SC is literally three miles from my house and they do not approve the lap band, I was told. Another thing, the NC policy doesn't require 6 mos. of supervised diet but they do require positive proof of morbid obesity for 4 out of the last 5 years. Go figure..all BCBSes write their own policies and have their own restrictions. I can tell you that the lap band studies have been proven and many of the ins. companies are now adding it to their list of approved weight loss surgeries. Remember, the first hoop you must jump through is your company policy. If your company policy does not include WLS, it doesn't make any difference what BCBS says, it's not covered...your company didn't select that option when they bought the policy.

without a fill of somesort you're almost wide open. Read the posts of many others, the fills are the key.

Many of us, me included, seem to think it's "us against the ins. companies." Especially when it comes to WLS, and specifically the Lap Band. It is relatively new and ins. companies were understandably cautious about approving something without positive scientific evidence and studies that it worked. The jury is in, the lap band studies do support the claims for substantial weight loss. BCBS and others are rapidly coming online and paying for the procedure. In your case, the best advice I can give you is to call your ins. rep. Ask for a representative who is familiar with WLS. They should be able to lead you, online, to the corporate medical policy area. Your ins. co. will have a written policy for WLS and it will tell you exactly what they will pay and what is excluded. My BCBS rep. pointed me to the site and I printed out the policy for NC which was modified around Feb. 1st to specificially include "gastric banding (a.k.a lap band) as an approved procedure. I can't possibly imagine a company who would approve a procedure where a necessary part of the medically implanted device is not covered. That's like saying they'll pay for heart angioplasty but you have to buy your own stints. You got some bad info somewhere, me thinks. JB

The port is a part of the Lap Band, not an accessory like fancy hubcaps on a car. Are you dealing with a reputable bariatric surgeon who is familiar with this procedure? How could any ins. co. justify saying the port was not necessary part of the procedure? Anyone else ever heard of this? JB:confused:

So sorry to hear you are discouraged, but, listen to me and others....keep up the fight. Things are changing at BCBS...you will win in the end. Keep the faith and keep the pressure on.

I called BCBS and spoke with a representative that was vaguely aware of a change in the policy. She was very helpful and was able to direct me, while online, on how to find the policy so we both could read the changes. In NC, the policy for surgery for morbid obesity HAS changed and "gastric banding," as they call it, (the only one in the U.S. that is approved is the Lap Band) is now approved, providing you qualify.

Your informaton says "10 cc band." I thought there were only two bands in the U.S. (and Mexico?), a 10 mm band and a VG(?) band? Something like that. The 10 mm means it's 10 mm around, but it only holds 4 ccs of saline, I think. Just curious.

The 6 months of medically supervised diet sure seemed like a bad idea. Glad they revised their policy. BTW, you have every right to call BCBS, it the gal was confused, that's her problem. Keep after them but don't argue or raise your voice. Calm, professional pressure. Aren't karmas fattening? JB

Jane, your ticker says you've lost 20 lbs. and you were banded one month ago? Geeze, that's 240 lbs. a year. And you haven't even had a fill yet! What were your expectations? JB

This is the problem; the individual BCBS organizations make up their own rules. I shouldn't use the term "make up" I read the BCBS of NC policy and related studies...these folks did their homework. However, when it comes to making the "Corporate Policy for Surgery for Morbid Obesity" they all have their own slant on things. As an example, NC does not require "6 months of medically supervised diet." The do require proof that the insured has been morbidly obese for 4 out of the last 5 years. That was no big deal for me, I was obese in kindergarten. JB

I should have said BCBS of NC's policy for gastric banding is restricted to a max BMI of 50. Other BCBS policies may be entirely different.

I am NO expert on this subject but I do have a few ideas to share. I wrote a post on this thread the other day in which I said you have two big hurdles to overcome and then many small ones. First big hurdle: Does your company insurance cover weight loss surgery? If they don't then you should go talk to your employer. If they do, most of them don't specify what type of WLS they cover...only that it's a covered expense. If it is covered, then you need to find/read the BCBS policy for Surgery for Morbid Obesity (ask your BCBS rep. to help you find it). Since you're in SC, you need THAT particular policy, not one from NC or anywhere else...they all seen to be a little different. The second big hurdle is SC may not yet approve gastric banding...NC just approved it a few weeks ago. Seems like many of them are now adding it to their coverage. Now for the bad news. Even if SC does allow it, you may not qualify. It is limited to BMI (Body Mass Index) of no more that 50. I don't know how tall you are but at 450 lbs. I would think you are way over 50. Have you considered gastric bypass? If your company allows WLS surely BCBS of SC covers RNY (gastric bypass) as it's been approved by almost all ins. companies for years. Good luck!! Keep after it. Don't give up. JB

Denise, and others, I think each BCBS entity has it's own set of policies. I am looking at the North Carolina policy...it says Blue Cross Blue Shield of North Carolina, Corporate Medical Policy, Surgery for Morbid Obesity. The first issue is not with BCBS, however, it's with your company plan. If it excludes WLS you are probably screwed. If it includes WLS then it depends on the particular BCBS. My case is a perfect example. My company's policy included WLS, BUT, BCBS of NC specificially EXCLUDED "gastric banding." Not knowing this, I went for my evaluations and Dr. appt. 3 years ago. Two things changed my mind. First, the doctor had only done 7 lap bands and second BCBS called gastric banding "investigational." They don't cover "investigational" procedures. Then a year or so ago, I started hearing of people with BCBS who were being approved for the lap band. I couldn't believe it...I checked NC...nope, still same investigational status. Then about a month ago, voila!!, the policy changed to include "gastric banding," i.e., the Lap Band. I have my Dr. appt. this Friday. JB

Damn. I already had plans for the Power Ball money. Oh, well. :cry John

Hi guys, tired of being fat....yeah, men get tired of it too. Also tired of waiting on penurious BCBS of NC to get off their fat duffs and admit that the LAP-BAND is more than an "investigational" tool. Sooo, this week, after waiting three long years for BCBS to come around I gave up, waved a chicken wing in the air, admitted to myself that I must either take my chance on several co-morbitities or self-pay. The self-pay won out. I called Dr. Voellinger's office, they faxed the "packet" I filled it out, attached my $150 "processing fee" and stuck it in the mailbox. Flashback three years to the fall of '04, I filled out all the paperwork, was accepted, went to the meeting, and then had an appt. with Dr. V. He accepted me and scheduled me for the other tests. Then I found out he'd only done 7 LAP-BANDS and BCBS wouldn't pay for a penny of it. So I decided to wait. What I need to know now is what's your opinion of Dr. V? I thought he was fine back then but there must be many of you who have had ABG surgery by him by now. Is it Dr. V. or should I research Dr. Bauman up north. I live in south Charlotte so Dr. Bauman is automatically my second choice unless there's a reason....skills or big $$. Thanks, JB