lisahg

How are you doing? What was your hospital experience? Do you have any tijps to pass along? My surgery is Dec. 26th in Buffalo NY. I can't wait to join the losers bench this month but I have to admit I am getting a little more nervous as the date gets closer. Tell me all about it. Thanks Lisa

After 2 insurance denials, I was finally approved via an external appeal to an independent review organization. I just got my December 26th surgery date this week. I guess my surgeon is super busy because it was either Dec. 26 or wait until Jan. 23rd. I am so excited! It will be a liquid Christmas dinner for me this year, I say yum-yum, bring it on :cheers2: ! I will be sleeved at Buffalo General Hosp. Buffalo, NY by Dr. Aaron Hoffman.

After 2 insurance denials, I was finally approved via an external appeal to an independent review organization. I just got my December 26th surgery date this week. I guess my surgeon is super busy because it was either Dec. 26 or wait until Jan. 23rd. I am so excited! It will be a liquid Christmas dinner for me this year, I say yum-yum, bring it on :cheers2: ! I will be sleeved at Buffalo General Hosp. Buffalo, NY by Dr. Aaron Hoffman.

Hi All I am so excited to report that I have been finally approved for the sleeve through Highmark BCBS! I was initially denied in August, appealed and denied again. I then filed an external appeal through an independent review organization and finally found out today that they overturened Highmarks decision. Yay! I did mega research in writing my appeal letters to substantiate my case, but it was worth it. I can wait until tomorrow to call the surgical coordinator to see when I can have a surgery date. Lisa

I am still waiting to hear, Highmark has had my appeal for 2 weeks and they have up to 30 days to respond. I am glad to hear that your daughter got an expedited appeal. Have you gotten a decision yet? If I am denied again, I plan to move ahead with an indepedent external review through the state (not sure of the proper name for that) of my case. Good luck to everyone dealing with their insurance.

Thanks for your reply and support! It is pretty discouragning to have done all the prelim. stuff and then get denied. Apparently there is a stipulation with my bcbs that you have to have a bmi of at least 50 to qualify for the sleeve. I didnt realize this when I first started this process but I still dont plan to go with the band or bypass. As a result of doing research for my appeal letter, I learned that the vsg was historically performed at the first in a 2-stage bariatric surgery (the 2nd being the roux-en-y or bd switch) for people with a bmi over 50 that are high risk. So my insurance hasnt updated their knowledge on the sleeve and its benefits for lower bmi people. I hope things go smoothly for you. Lisa

Hey Everyone, About a week ago, I was denied by Highmark BCBS for the sleeve based on it not being medically necessary and appropriate. My BMI is 36.4 with associated Hypertension and Type 2 Diabetes Mellitus. My surgeon did a peer-to-peer review this week but got no where with the physician on the review committee. Based on the fact that the peer review didnt make any progress, what are the chances that my appeal letter will have the denial overturned? I am kind of bummed because I think my chances are not so good now. Thanks Lisa

Hey Folks, I just found out this morning that Highmark (Pa.) BCBS has denied by request for VSG . Apparently their medical policy requires a BMI greater than 50 and VSG as a 1st stage in a two stage procedure. My BMI is 37 with 2 comorbidities, I plan to appeal with a letter and substantiated research articles. My surgeon's coordinator says the surgeon will do a peer to peer review next week. For those of you who have gone through this, are peer to peer reviews typically successful in getting the insurance decision reversed? Thanks Lisa

Hi I have Highmark BCBS too and am hoping to be approved for the sleeve. My paperwork was submitted last week but havent heard anything yet. I plan to call them a couple times a week until I get approved/denied. When I contacted Highmark to comfirm my paperwork was received, I was told a predetermination could take 4 weeks. I didnt question them on it but that just seems like a crazy amount of time! Please do a follow-up post to let me know how you make out with the insurance. Lisa

I can totally relate to your frustration too with Highmark BCBS and the 50+ BMI requirement. I live in NY and am hopefully getting the vsg in Buffalo, NY but the insurance is within PA. where my husband works. My BMI is 37 with hypertensiion and diabetes. I knew about the 50 BMI requirement but went through all of the pre-surgery steps anyway. The bariatric coordinator submitted my paperwork for the vsg last week. So, keeping my fingers crossed. When I called Highmark bcbs today to comfirm they had received my paperwork, I was told a predetermination could take from 4-6 weeks!! Oh my god, I hope that is a gross exaggeration. I guess I am preparing myself for being denied. But I dont feel the bypass or lap band are appropriate surgeries for me due to related circumstances I hope I can convincingly express in an appeal letter if it comes to that. I am hoping it might be easier to win an appeal with Highmark since they at least offers the vsg for a certain population as opposed to an insurer that doesnt cover it at all. Good luck to you! Lisa

Hi Vicki S. I did a search on Buffalo NY because that is where I am looking to have the surgery. I see that your surgeon was Dr. Hoffman. Is his practice/office out of Buffalo General Hospital? Does he perform the sleeve or just bypass? Any information would be really appreciated! Lisa