Kat Crowder

Do you have BCBSIL?

Yep, I do. However, the office insisted on putting me through with diabetes and sleep apnea as my two official comorbidities, when I told them I didn't have diabetes, I had prediabetes, and my comorbidities were sleep apnea and dyslipidemia. Also, they didn't bother getting supporting information from my regular doctors. So, I've been denied and they're going to appeal, and I've insisted on them getting all my medical records to prove things.

I'm approved thru BCBSIL. Their approval was easy. The problem was I had to get approved thru an outside agency because my insurance is thru the city of chicago and they have their on guidelines. It took a week for an approval that should have only taken 2 days. I called every day for 4 days and finally on Friday I talked to the the nurse. It took her all of 1.5 min to look over my paperwork and say she would send it on to the doctors. My approval came thru on Tuesday!!!

How awesome for you! I'm having a heck of a time with the insurance people at my surgeon's office.

Interesting thread - I looked up the BCBSNJ medical policy and it said the sleeve was only for BMI > 50, but if adrimc26 got approved with a BMI of 43, it looks like they're making exceptions.

Yup. They bill more when insurance is involved. Doesn't seem right, does it?

~Amy

I actually think it makes more sense than the other way around, which is often the case. This way, they're providing discounted care to people who have to self-pay, and charging more like the actual cost to the insurance companies. What I hate seeing is when something "costs" X dollars, but the insurance discount is huge because the insurance company has agreed on a price that's so low that self payers need to make up the difference. That happens a lot in laboratory testing, for example. $700 tests can cost the insurance company only $25, but if you aren't on insurance you need to pay the full price or try to negotiate it down.

I suggest finding out what your insurance company's medical policy on weight loss surgery is. It seems like most of the BCBS websites have Medical Policy under their "Providers" tab, and you can find what the specific requirements are.

I think it's important to educate yourself straight from the source, and get all the information you can. I'm finding that I really need to guide my surgeon's insurance person to gather the right information to submit, which is frustrating, but I'm the person most invested in getting my insurance approved.

Good luck!

Hello everyone! I recently finished up most my clearances for BCBS of DE...I just have one nutrition class left in May.

Immediately following my 5th nutrition class I stopped to speak with the nurse to discuss a possible surgery date. At this time, I was informed that my insurance company still views the sleeve as a two part procedure; therefore, they require a BMI of 50 or higher. My BMI is 38.

I'm not really sure why it took five months for someone to share this information with me, but I am absolutely livid!

I would be livid, too - The person in charge of insurance at my surgeon is crappy, as well. Here is the link to the medical policy for BCBSDE - since i have BCBSIL and have been spending a lot of time checking out medical policy, I figured I could find it in a similar place for you:

https://www.bcbsde.com/ProviderPolicies/public_site/7.01.36_Obesity.htm

It states:

"The following procedures are covered for the surgical treatment of morbid obesity when all of the patient selection criteria are met.

(other procedures deleted here)

· Sleeve Gastrectomy (43775)

For the superobese patient with a BMI of ≥ 50 who is 18 years of age or older, sleeve gastrectomy is an eligible procedure as a first stage of a two-stage procedure, or as a sole definitive procedure.

A sleeve gastrectomy is an alternative approach to gastrectomy that can be performed on its own, or in combination with malabsorptive procedures (most commonly Roux-en-Y gastric bypass or biliopancreatic diversion with duodenal switch). In this procedure, the greater curvature of the stomach is resected from the angle of His to the distal antrum, resulting in a stomach remnant shaped like a tube or sleeve. The pyloric sphincter is preserved, resulting in a more physiologic transit of food from the stomach to the duodenum, and avoiding the dumping syndrome (overly rapid transport of food through stomach into intestines) that is seen with distal gastrectomy. This procedure can be performed by an open or laparoscopic technique. Some surgeons have proposed this as the first in a two-stage procedure for very high-risk patients."

And then below that it lists the patient selection criteria which you have been working to meet (besides already having the BMI with comorbidities).

This policy could be read two ways. The 50 BMI information could be merely that - information about how the sleeve applies to 50 BMI patients, or it could be considered selection criteria. It doesn't exist in the patient selection criteria section, though, and I think that implies that it's informational. The descriptions of the other procedures don't provide any selection criteria.

The insurance companies make it difficult for you to involve yourself in the insurance approval process, which is frustrating. BCBS-IL has a peer-to-peer line where your doctor can call to discuss the denial, but the surgeon doesn't want to deal with the insurance issues, that's theoretically what he pays his insurance staff to do. And they're not medical people, they're paperwork people.

Did you get a denial letter, or is the office staff interpreting the medical policy? If it's the latter, I would completely argue the point. Print out the policy, highlight what's relevant, and explain that the sentence about 50 BMI patients explains what it is for 50 BMI patients, and doesn't exclude its use on others.

I agree with reporting her, too. If you request to speak to the doctor, they have no right to refuse you.

Yeah... I got my date before my info was submitted to insurance. I lost 11 pounds on my pre op diet. It was 1200 calories and I did liquids for the last 3 days.

I hope everything's gone well for you! Two days post op now?

My insurance ought to pay, too. They're just being annoying. They want your doctor to document medical necessity by listing 2 comorbidities that have not responded to maximum medical treatment, and when my doctor did that, they still denied it, because apparently she didn't justify it the way they wanted. It's not like they provide a form or anything. Why couldn't I have gone through this exercise while I was doing the 6 month supervised diet, worked out the kinks, and gotten conditional approval pending the diet program? Frustrating. I'm so ready now, and I'm annoyed by this stupid back and forth of documents. Gah.

I've been researching prices' date=' and found many different prices. Why is www.alighterme.com (http://www.alighterm...urgery-specials) so low. The price is just 4,500.

I've seen others around this price but I'm curious to see why so many companies compete on price? Should one go for price first, or go for surgeon first. Any help will be appreciated.

Even looking at this site, there are a lot of ads with the price first.

There are a lot of factors that come into play when you're deciding on surgery. If it's not something covered by your insurance and you're not wealthy, you're going to look at cost as one of those factors. I think everyone would like to have the best outcome at the lowest price, and it's a matter of massaging all the data to decide what's best for you.

Right now I'm not thrilled with my surgeon's insurance department - maybe that's something else you'd want to look at. Is the surgeon close to you, or if not, is there a doctor who can do followup appointments? How many surgeries has the doctor done and what were the outcomes?

I would universally say to not look at price exclusively. You can definitely consider it, though. Make sure you know what that price includes, as well, and then figure out the cost of the needs not covered.

Those are just my thoughts, having not yet done it. There's a surgical center that's a Bariatric Center of Excellence right near me, and my insurance covers them (although I just got a denial letter that I have to appeal), so I just need to cover my max out of pocket, hopefully. Good luck!

Soooo... I was thinking that this really wasn't going to happen for me. I had taken all of the steps' date=' but insurance was taking so long to approve me. IMHO! However, today I got the call! I'm approved and having surgery in two days!!!!! Now I feel like I'm on an emotional rollercoaster... I'm excited, nervous, sad, and anxious all at the same time! No matter what, I will be having surgery and look forward to my new life![/quote']

Good for you! I just got a denial letter, which made me cry, because they have everything they need and they're just being jerks about it. Two days after approval? Don't you have a preop diet or anything to follow? That's so exciting!

I take Effexor xr's too and I'm worried about taking it with nothing solid to eat in my stomach because they really hurt on an empty stomach as I'm sure you already know. I've heard there is a pill form but its not extended released and has a lot more side effects such as vivid or scary dreams WTH? I plan to ask my doc before surgery on Thurs. Let me know if you find out anything before then?

I spoke to my psychiatrist today, and she said that it was OK to dump the Effexor XR capsules out, and take them with whatever I can tolerate at the time (whether it's Clear liquids at the time, or so on). She said that especially with such big changes going on, it's important to stay on the anti-depressant meds, and I agree. Vivid or scary dreams are things I get if I miss a couple days of the Effexor XR, so I can see it being a potential side effect of the non-extended release, too. Yeah, you might get a little more nausea on a stomach without food - but I frequently take my pills with no food, or just with a Protein shake, and I'm used to it. Hopefully it won't hurt your sleeve enough to have to throw up, but I'm pretty sure you want to stay on it.

Cheers, and good luck!

Anyone on Effexor XR? I take the orange generic capsules. I've heard that XR's (extended release) don't tend to work for sleevers because of the lack of stomach acid to dissolve it. It's a concern for me because as anyone who takes it knows, it's got horrible withdrawal effects.

Another forum post says the surgeon recommended spilling the capsule into applesauce. I think I'm going to go in and talk to my psychiatrist about it.

I have my insurance preapproval submitted, I'm out in Lake Zurich, but still Chicagoland.

It is my employer requiring the 6 month supervision. At first I was upset but I really need the time to come to terms this is real.

Awesome attitude - it's real, and it's for life, and the prep is going to mean a lot. It's not a delay, it's just part of the process.

I have BCBSIL, but mine still requires a 6 month supervision. I'm ok with it. It gives me a chance to better prepare myself.

I'm four months into my 6 months, and don't require the supervision any more so I'm moving forward. It was inconvenient to take a half day off work every month to go to the supervision visits. Furby, I'm surprised that you still require a 6 month supervision. If you go to the BCBSIL website, access the providers page, then go to medical policy and search for bariatric, the bariatric surgery policy doesn't require 6 month supervision. Is the 6 month supervision a special restriction put in place by your employer?