Walter Lindstrom

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!

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.

Not dramatic at all!!!
I agree with you. I wonder why GERD is a big deal. I would have even done bypass instead of sleeve in the beginning.

I had sleeve 3/26/18 rny on 11/22/19

Awesome. I’m so jealous lol
I hope they approve it. Penciled in for March 18. If all goes well.

Sadly this has been going on for a long time. Here is a link regarding a similar situation (not Geisinger but with Aetna) which may help: https://wlsappeals.com/2142/walters_bariatric_surgery_blog/gained-weight-pre-op-diet-now-what/

I had my band removed and RNY at the same time. DIfferent surgeons do it differently. make sure to go to someone with a ton of experience. It makes all the difference. As far as insurance it really depends on which BCBS. I was denied and hired lindstrom obesity advocates. If you have any issues call them and have a free consultation. They are amazing. I have BCBS Illinois and had a terrible time with them. As far as your job and work, it depends on how you recover. I definitely needed at least a week to be able to do anything. Two weeks I would've been fine.

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!

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!

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

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

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

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!

Thank you, Walter! Me too!!!

Sent from my SM-G965U using BariatricPal mobile app

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

BCBS of IL. Kept saying that I was having a lapband removal at the same time as getting sleeve done. I had the lap band removal in September and they approved it . We dont know why they kept saying that both would happen at once. The dr. Didnt submit it this way. Also this was the 1st time GERD was part of the reason to deny the claim.

GERD was never submitted as a reason to remove lap band.

Anyway. We appealed to the state of Illinois because of all this and they told them...to approve the Sleeve.



Sent from my SM-G965U using BariatricPal mobile app

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

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!

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!

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

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!

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!

lindstrom obesity advocacy helped me. they are experts in WLS appeals - you should give them a call. they give you a free consult. www.wlsappeals.com

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

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