Walter Lindstrom

My bad! I probably need to change my signature because I thought it was there automatically. Thanks for letting me know. The telephone number is 1-877-992-7732. You will speak with Kelley, my better half, partner and wife of nearly 39 years. She’s talking to someone now so leave a VM message if she can’t answer and she will call you ASAP. Thanks!
Walter

I’m sorry to hear about your issues. I hope you have not yet exhausted your appeal rights. I urge you to call us for an assessment of how we are able to help. 25 years of advocacy and thousands of appeals later, we know what we are doing 👍🏻 Ask around the BariatricPal site.

I'm sorry you're going through this. I can certainly help interpret the language (being an attorney and patient advocate who has handled over 10,000 bariatric surgery appeals over the last 25 years or so). Sorry to say I am pretty sure this Rider is an attempt to exclude all bariatric surgery that may have previously been covered. If you'd like to contact our office for an analysis I'd love to sift through what you're dealing with so you know your coverage from the outset. As mentioned by other folks responding to your question, I would want to see the existing coverage booklet (as a PDF) that this rider is attached to so we can piece together for you what's going on. You are correct in being cautious about moving forward and our office is here to help. Call us at 1-877-992-7732 and we can discuss this in detail - - - it's going to be a complicated puzzle to put together, but nothing we haven't been doing for a couple of decades!

BCBSTX offers many plans depending on the employer type (large or small group, individual, state plan, unions, etc.) - some cover, many don't (sorry). Since you haven't had a preauthorization request sent to them yet, there is nothing that's been denied. This gives you time to locate your Certificate of Coverage or Summary Plan Description - the long booklet (usually 100 plus pages and not to be confused with a "Summary of Benefits and Coverage") so you can look for yourself as to what is / is not covered. We're coming up to the end of the year so you ought to see if your benefits change to a new payer or plan type on 1/1/2021 if you don't have coverage. Contact us if you want some free help with the process - Kelley will be happy to guide you in the hope it leads to an approval. Good luck!

We've successfully helped several GHI members get revisions so please be optimistic - BTW, whether or not you regain weight is IRRELEVANT since changing eating patterns due to severe GERD is not only common, but often a necessary way people can tolerate ANYTHING! Let us know if you're submission is denied before anyone at the doc's office does something that might hurt your chances of being approved and GOOD LUCK! GERD really sucks so hopefully you get approved without a problem.

So happy and honored that today is our 23rd anniversary helping #patients fight insurers denying necessary care. Looking back, I see how far we've come and that gives me hope. Looking forward, I know we have a ways to go but we will continue to battle!

Hi Butterfly512,

We handle hundreds of these kinds of denials (band conversion cases) so I wanted to share something before you went to surgeons thinking you might have to talk them out of a "required" six-month diet. Remember, despite what you might be told, there is no evidence-based medicine to support these bogus 6-month diets and the society of bariatric surgeons has soundly rejected the concept of insurer requirements like this. However it is quite possible that isn't even relevant in your case if you are having your band removed (with a conversion to a new procedure) because of a complication . While most people only think of band complications as being a flipped port or the band slipping or eroding, there are other complications we see every day, most of which result in stalled weight loss, weight gain, severe reflux and other serious problems. Often overlooked, even by surgical practices whose dieticians are often trying to paint we patients as the ones to blame if a surgery "fails", is a recognized complication called "band intolerance." That means, in essence, you cannot get it adjusted in the "green zone" so you're either too tight which results in severe reflux, regurgitation, vomiting, and pain (sometimes) or you are open and getting no satiety or restriction and can eat anything. Either way is bad but having a band too tight is often something people try to muddle through - often by eating softer, usually higher calorie foods because they go down easier than the dense Proteins we are supposed to eat. When complications are present and your band has to be removed because there is no other way of treating your symptoms, there is no medical reason to be forced to undergo a 6 month diet. Think about it and you know the answer to this: how is a diet going to help alleviate something that can only be fixed surgically? Sadly too many bariatric practices simply have knee-jerk reactions about these diet programs which make no sense - they do it because they have allowed insurance companies to make these medical decisions.

Hopefully this information helps you interview surgeons in your area and gives you some "ammunition" if someone in their office (or the surgeon themselves) tries to convince you that going on the dreaded six-month diet is necessary. And feel free to call us at 877-992-7732 if we can help in any way, even if you haven't had a request sent to your insurer.

Good luck! For Patients' Sakes - Drive The Bus!

That's great news! Congratulations! We hope you have a completely BORING and UNEVENTFUL surgery - the best kind to have - followed by an easy recovery as you move toward a healthier YOU!

Best, Walter

2 minutes ago, lilDanille said:

I have the centennial care in New Mexico

Sent from my moto e5 play using BariatricPal mobile app

Ahhh - - that's the New Mexico Medicaid plan offered through BCBS New Mexico. They will undoubtedly have a separate set of "rules" which might differ from "traditional" BCBSNM medical criteria. Your surgeon's office (Prebyterian perhaps?) should be able to walk you through that specific process and time frames involved. Good luck!

Since these are independent members of the national "Blue Cross and Blue Shield Association" it's unfortunate but not all "Blue Cross Blue Shield" companies treat bariatric surgery in the same way. Some are great - others? Not so much. Let us know which specific company you're with and where you are located so you can get the right answer, FOR YOU. Here is a link that identifies all the BCBS Association members in case it helps anyone:

BCSB Companies and Licensees

Exactly! It's a medical decision which should be reserved for physicians. However, I hope bariatric programs don't make mandatory diets a requirement of their programs as a knee-jerk reaction to insurer demands - even when insurers don't "demand"! Why? Because there is no evidence-based medicine to support mandatory diets! Here is more information to help:

ASMBS Position Statement On Insurer-Mandated Pre-Surgery Weight Loss Requirements

Hi! Stay optimistic but be prepared for UHC doing the wrong thing. The peer to peer process isn't often a great process for patients - it often starts with the UHC medical director and your surgeon having trouble connecting on the phone to even discuss things. So don't let that drag out before you act because even if/when they do connect your surgeon may be dealing with a UHC medical director who simply doesn't have the authority (or the expertise) to consider your individual circumstance. So be proactive and take control - Your best shot at overturning the denial may be the patient appeal process and you don't need to wait for the peer-to-peer to get started on an appeal. Your bariatric provider may tell you to wait for the peer to peer but you'll feel better if you're doing something proactive and know you're learning about the process. And if the peer-to-peer is successful (HOPEFULLY) than you're good to go and you've lost nothing. But you may want to call us to help walk you through things - we do a lot of UHC band removal/conversion appeals and we know their process better than anyone. Hope this helps and good luck!

I understand your anxiety but you should go to your appointment focused on how surgery can help you NOW because of your health NOW. I'm linking a blog post I wrote which should give you some comfort (I hope). Aetna has played this sad, pathetic game for quite some time (as have many other payers) but you can't stress over it - just take care of yourself - prepare for the journey - and know that if they say "No" it isn't the end of the world. That answer isn't final - you can fight and you can win. Hopefully they do the right thing right away. Good luck and let me know if we can help. Aetna's "Two Year History" Denial Overturned

It's important not to get caught up in a specific number - you haven't gained excessively and you have changed behaviors. We stress that your insurance company - whoever they are - is NOT THE BOSS OF YOU when it comes to pre-surgery diet programs. You Gained Weight During Your Pre-Op Diet . . . Now What? Good luck!

Sorry to say that BCBS AL truly is one of the most backward companies we deal with. Check out Horror Story #2

PLEASE be careful about just sending pics or random records hoping it will show them what you've been dealing with for way longer than 3 years because I promise you they really aren't interested and you need to be VERY CAREFUL about appealing on your own because they have quite a limited process - you want to make sure you take your best shot. If you want some guidance and suggestions which may help, please feel free to give us a call. You might find it helpful.

Hi Bianca,

There are some Florida Blue policies which do cover surgery (including the sleeve) and many which do not. So the big question is what certificate do you have? You can look it up on their portal as a Member but at least I can give you the link to their Medical Policy:

Subject: Bariatric Surgery - Effective 12-15-2018

Here is their general criteria:

Selection criteria (Adults)

*Severely obese with a BMI ≥ 40 kg/m2, OR

*Severely obese with a BMI ≥ 35 kg/m2, with at least one comorbidity refractory to medical management (e.g., type 2 diabetes, hypertension, coronary artery disease, obstructive sleep apnea, GERD, osteoarthritis, pseudotumor cerebri), AND

 Does not have a medically treatable cause for obesity (e.g., thyroid or other endocrine disorder), AND  Has made multiple attempts at non-surgical weight loss (e.g., diet, exercise, medications), AND  Has received psychological or psychiatric evaluation with counseling as needed, prior to surgical intervention.

Good luck! Hope this helps. Happy New Year!

While working on an appeal to the Office of Personnel Management for someone denied a conversion of an LAGB to VSG, I noticed a very significant change that may help anyone who is going to be covered in 2019 under the Federal Employees Benefit Plan (FEP). For many years their criteria for surgery used to require a TWO-YEAR history of morbid obesity. That is changing to ONE YEAR. That is a big deal and might be very important for many folks covered under the FEP plans. Here's what they say about the change:

"We now provide bariatric surgery benefits for members who have a diagnosis of morbid obesity for a period of 1 year prior to surgery. Previously, the requirement was a diagnosis of morbid obesity 2 years prior to surgery. (See page 69.)"

This is a important for anyone who cannot prove they meet the BMI criteria for two years regardless of whether they are (a) trying to get FEP to approve their first surgery OR (b) anyone seeking a revision / conversion for reasons other than a "complication" related to their original surgery. I'm attaching a copy of the 2019 Service Benefit Brochure and here is the link: 2019 FEP Service Benefit Plan

I hope it helps. Happy Holidays to everyone!

2019_SBP_ Brochure.pdf

I wouldn’t expect changes when 2019 rolls in since this is a recent update, but make sure you keep tabs on it just to be sure! 👍🏻

Hi Kimmie K,

I believe this link to Anthem's updated bariatric surgery medical policy is exactly what you are looking for: CG-SURG-83 Bariatric Surgery I'm also attaching it as a PDF. This contains all the Anthem req'ments as of their October 31, 2018 update. Hope this helps!

CG-SURG-83 Bariatric Surgery and Other Treatments for Clinically Severe Obesity.pdf

I was working on an appeal and came across the 2017 Kaiser WA Bariatric Surgery program booklet. I don't know if there is an updated book for 2018 (or soon 2019), but I figured it would not hurt to provide the link in case anyone wants to download the PDF. It is:

KP Washington 2017 Guide for the Bariatric Surgery Program

Happy to share - best of luck.

YOU MUST READ THIS if . . .

Your health coverage comes from Blue Cross Blue Shield of Illinois, Texas, Montana, New Mexico or Oklahoma in 2019! (And probably should read it even if you're not!)

Why? Those 5 companies are part of HEALTH CARE SERVICE CORPORATION (HCSC) and they are making a major change which affects anyone insured by them in 2019 who is considering having bariatric surgery. The HCSC Bariatric Surgery Medical Policy no. SURG716.003 is going to become effective February 1, 2019 and, believe it or not, they are eliminating any formal requirement that patients engage in supervised weight loss for a particular time frame (e.g. 3, 6, 12 months, etc.) prior to surgery.

READ MORE HERE: BIG NEWS! Several insurers are going to REMOVE pre-surgery supervised diet requirements

This may have been discussed before but for anyone covered by CIGNA or one of its affiliated companies, they have abandoned their prior formal requirement of a specific duration (e.g. 3 months) in favor of this language:

• A statement from a physician/physician’s assistant/nurse practitioner/registered dietician (i.e., other than the requesting surgeon) that the individual has failed previous attempts to achieve and maintain weight loss by medical management.

This is the old language:

• Medical management including evidence of active participation within the last 12 months in a weight-management program that is supervised either by a physician/physician’s assistant/nurse practitioner or a registered dietician for a minimum of three consecutive months ((i.e., ≥ 89 days). The weight-management program must include monthly documentation of ALL of the following components:

 weight

 current dietary program

 physical activity (e.g., exercise program)

Programs such as Weight Watchers®, Jenny Craig® and Optifast® are acceptable alternatives if done in conjunction with the supervision of a physician/physician’s assistant/nurse practitioner or registered dietician and detailed documentation of participation is available for review. However, physician-supervised programs consisting exclusively of pharmacological management are not sufficient to meet this requirement.

Anyone covered by CIGNA now and going through a mandatory weight loss program under the old medical policy should request their surgeon/bariatric program to submit their request for approval NOW and not wait to finish the supervised diet. You might get some push-back from crusty bariatric practices or surgeons, but hopefully they will help you. The new policy is more favorable to patients, and because it is the medical policy in effect for anyone having surgery after October 9th, we take the position this is the operative medical policy - NOT the policy at a patient's "starting point".

Call us at 1-877-992-7732 if you have questions about this or are in need of any information about what you need to do if you have been denied by your insurer - whether it is CIGNA or any other payer. Good luck to all!

CIGNA medical policy effective October 9 2018.pdf

My apologies if "cross-posting" here is bad form - - just wanted to share a Halloween Blog that's very relevant to the season!

I was unable to locate specific guidelines for the BC Complete Medicaid program dealing with bariatric surgery. I don't believe they have a separate criteria but I may be wrong on that; however here are their guidelines for other plans. I've included a LINK and the PDF. Good luck!

Michigan BCBS Bariatric Medical Policy

I've also attached the PDF file in case the link doesn't work.

BCBS Michigan Guidelines.pdf