PNW_Sleever

I decided to tell my story about my fight with BCBS FEP (Federal Employee Program) to cover my sleeve in hopes that maybe it will help someone else. This process took over a YEAR. It was discouraging at times, but I was not going to give up. It’s a long read, but trust me, I shortened it as much as possible.
The process started in September of 2010. I decided I was finally going to do something about my weight and I was looking into the lapband. My husband and I went to a weight loss seminar at one of the surgery centers in my area. During the seminar, the surgeon started talking about the Sleeve and I was immediately excited about it. The idea of having a foreign object in my body didn’t appeal to me, and I had already made the decision with my family not to get the gastric bypass. The Sleeve sounded perfect and I had my heart set on it. After the seminar I spoke with their insurance person, and she said “oh, I’m sorry, your insurance won’t cover that”. Of course I was totally disappointed, but I wasn’t going to change my mind. The next day, I looked at the plan brochure and came across this:
Gastric restrictive procedures, gastric malabsorptive procedures, and combination restrictive and malabsorptive procedures to treat morbid obesity – a condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with co-morbidities who has failed conservative treatment; eligible members must be age 18 or over.
This clearly states that it covers the Gastric Restrictive procedures, which the VSG is considered. I called my insurance and gave them the CPT code for the VSG, and the representative said “Yes, it is covered as long as you meet the criteria listed.” (which I did). I was over the moon. I started setting up all of the testing required before submitting to insurance (psych eval, visit with nutritionist, etc.).
November 17, 2010 – the surgeon’s office submitted my paperwork to BCBS FEP
November 29, 2010 - I received a denial letter from BCBS stating that the Sleeve Gastrectomy is considered not medically necessary as a treatment for morbid obesity.
December 10, 2010 – the surgeon’s office submitted a letter of appeal on my behalf.
December 16, 2010 – I received another denial letter that stated “sleeve gastrectomy is considered not medically necessary because it is not appropriate to prevent, diagnose, or treat the condition, illness, or injury."

After I received this letter, I contacted BCBS FEP again. I told her that I spoke with a representative previously who told me that the Sleeve Gastrectomy is covered, and asked why it was being denied. The representative on the phone said yes, it is covered, but I’m not showing that we ever received any paperwork for you. Ugh! She said it could have been sent to the wrong office. I sent her all of the info again, she called back to confirm that she received it and said she would forward it on to the proper department. About a month passes and I get a call stating that it was sent to the wrong area AGAIN and that it was forwarded on to Premera BCBS. During this call I learned that BCBS FEP in Washington State is run by the local administrators, so a lot of times the representatives give you information on the local plan rather than the Federal plan which is very different. Also, there is Regence BCBS and Premera BCBS. The representative on the phone told me that if the procedure will be done on an outpatient basis, it would need to be processed through Premera. If it will be done at a medical facility or hospital, then it would go through Regence. Is this not crazy? Moving along…
February 21, 2011 – I received a denial letter stating that there is no documentation of participation in a medically supervised weight loss program with regularly monthly follow up for a period of at least 3 months.

The reason I hadn’t done that was because I started this process in 2010, and it wasn’t part of the criteria until the 2011. Another set-back. I called the nutritionist and set up 3 months of appointments. After the 3 months of supervised visits, my surgeon’s office sent the paperwork to insurance again, this time stating that all of the requirements have now been met.
June 1, 2011 – A note was faxed back from BCBS FEP to my surgeon’s office stating: This was denied as not medically necessary, not relative to the 3 month supervised weight loss program. CAN YOU BELIEVE THAT??? Clearly I’m getting the run-around.

After that denial, I called BCBS and explained the situation regarding the request from BCBS to get the supervised visit, and then sending another letter saying that’s not why it was denied. I was angry. The representative on the phone said at first, “hmm, that’s weird, yeah it looks like they want you to get a 3 month supervised visit”, to which I told him that I had, and he said he thought then that it should have been approved. He said he was going to check on something and put me on hold. I was on hold for about 10 minutes before he came back and told me that he was sorry but it was denied. I voiced my frustration and told him that I was going to fight for this, first through the OPM (Office of Personnel Management – the governing officials over Federal Employee Health Benefits), and if that didn’t work I was going to get a lawyer.
June 24, 2011 – Received an APPROVAL from BCBS!!! YAY!!! It was funny how after I mentioned the OPM and a lawyer, I got an approval in the mail. The representative even told me that I would not be receiving any other letters in the mail.

I should back up just a bit because right before I got the approval, I was looking for information online about my insurance and I found a post from someone stating that it would be cheaper to do the procedure inpatient. I looked into this and really started considering it. If I went with the outpatient surgical center, it would cost me a little under $5,000 out of pocket. If I went with inpatient, I would end up paying under $1,000 out of pocket. So yes, the approval was wonderful news, and even after all that I went through to get it approved, I decided I wanted to do the procedure inpatient so as to save us some money. I had spoken with the outpatient surgery center and they didn’t offer to come down on the price at all, so I started pursuing another surgeon at a local hospital. They got everything going really quickly, but really wanted me to have a sleep study because if I did have apnea, they believed it would be helpful to have a CPAP during recovery. I did the sleep study, found out I have Sleep Apnea, and got a CPAP.
I mentioned earlier that there are 2 parts of BCBS FEP in Washington State. Because of this, I had to resubmit my paperwork to Regence as it was now going to be done at a hospital. Here we go again. The new surgeon’s office was to fax all of the new documentation, along with the old documentation, and I believe it got lost 3 times. :banghead: There were a lot of phone calls during this time, I followed up and followed up again to make sure everything was where it needed to be.
September 12, 2011 – I received another APPROVAL from BCBS, this time for the inpatient surgery!

This was the happiest day. I finally won the battle!!!

One more thing, when I notified the outpatient surgery center that I would definitely be switching to the inpatient facility, I got a call from the director of the outpatient center. He wanted to know why I left and I told him it was about the money, and also that I’d feel safer if I stayed overnight in a hospital. He offered to match the price I was paying at the hospital. I said thank you, but no. He called again and said that this was his final offer – he would give me the surgery for free, and also give me a $2000 credit for a future plastic surgery. Some people may think I’m crazy for this, but I turned down that offer as well. I just had a strong feeling about wanting to do it at the hospital and I had to trust my gut. When I talked to my husband about it, he felt the same way, so that made me feel better about the decision. In the end I only ended up paying $250 out of pocket. :biggrin:
SEPTEMBER 27. 2011 – SURGERY DATE!

THE BEGINNING

Hi there Smoggy.
Welcome! I'm pretty much a newb here too. I just had the sleeve done a few weeks ago and this is a great place to get info and support from other Sleevers.