thisislou

has anyone had any luck with BCBS of Tx. yet if so how did you do it..

I did get approval from BCBS IL after an appeal. Since the code 43775 is still "investigational" I would guess everyone would get rejected once "43775" is read. For me, the appeal was easy - I just stated the facts and within 2 weeks was approved (surgery scheduled for 7/14)

Lou

Does anyone know how to upload a file in an email. I have a PDF file 30 pages long that is full of shake recipes. I found it on another site and would share if I knew how.

Sorry don't know how - but would like it if you could email it to me @ steinbl@cfl.rr.com

thanks

Lou

My surgery date was has been finalized to July 14th @ 9:00 am?Liquid diet starts next Wednesday June 30th.

I had vacation this week that really helped with scheduling all the pre test ? UGI, pulmonary, some test today ? don?t remember the name but it?s something about a tube up your nose..

And blood work.

Any tips on good Protein Shakes? For those of you that have already started your liquid diet - what is your normal routine?

I'm told I should be in the hospital at least 3 days - does that sound normal?

Lou

Ok - add me to this list... I just got approved (or found out) on June 16th and have a tenitive surgery date of July 12.

I live in central Florida and Dr. Radulescu is the lucky doctor to do the surgery. His office said that my hospital stay would be a minimum of 3 days and I have a 2 week liquid diet. How does that match the rest of you? I have not read all 5 pages of this post yet ? so some of you might have already listed this.

Lou

Hi

I would be glade to give you some pointers - but not the letter. I can see it getting back to bcbsil with someone else's name on the header... not good.

Lou

The important thing to remenber is their procedure states that 43775 (VSG) is still investigational and is not approved. So as soon as they see that ? it is stopped. Going through the process a few times ? first for the lap-band, I realized ? it only takes one thing to kick it back ? fix that and they continue until the next stop.

My advice ? have a cover letter from your primary doctor that states everything ? your BMI, if under the magic 40 ? then your ?comorbid conditions related to obesity?, your 3 month ?Supervised weight loss program? and anything else that is required. That way it?s all in front of them.

Saying that ? count on it being rejected for 43775 and an appeal is needed. This goes to a 3rd party group that will actually look at your information and in my case overturn the denail based on the same information previous given ? but this time with a cover letter from me.

Hope this helps

Lou

Ok ? different story ?.

I just called BCBSIL and found out my appeal was approved for sleeve gastrecomy 43775?

It took them less then a week ? it was approved on the 10th ? did not find out until I just called.

?Reason: Approval is based upon recommendation by an external peer reviewer, after consideration of the member?s individual clinical circumstances?

Now I?m doing the happy dance ?

Lou

:001_cool:

Lou ... I was also denied the first time they sent it through under that code. there is another code I dont remember what it is(it is a combination of 4,8,3and 0 but I am dyslexic and dont remember which order) I will see if I can find it. When they submitted it under that number I was just denied for not having enough diet documentation. BCBS requires 3 months but Walgreens requires 6. But they did tell me that it is a covered benifit under that code so try it, maybe you wont have to appeal just resumit under the other code!

Hi

I could not find a code with these numbers. Any luck finding it?

Lou

Anybody got any recommendations on dealing with BCBS IL I have sumbitted everything once but did not have my 6 months of diet documentation. I am about to complete that and could use any info you having on getting approved. I had done everything 3 years ago and then found out I was preggers. Now I have been working at this again for 8 months and Walgreens(where I work) is requiring the 6 months its not even BCBS. Just want to make sure I get approved before my psych eval expires!

I also have bcbs il and was rejected a few weeks back for VSG. At the time - they said "43775" was still investigational. I know once they saw the code - they stopped and did not even look at my packet - they rejected it within hours. I started the appeal process. They sent my appeal to their "3rd party" people last week and say it could take 60 days. Someone on another forum stated that their doctor's office got an email from bcbs (a few states one of them was il) just changed their policy to now accept VSG. I check they policy daily and as of this AM, it is still dated 9/2009 and no.

Lou

Does anyone have information that can help me? I called UPMC Health Plan (University of Pittsburgh) in January and asked if I was covered for the VSG. The answer was yes. I started my 6-month Pre-Surgical supervised diet, weight program; lost weight, lowered my blood glucose, had my psychological evaluation and even met the surgeon. I thought I was ready to go. At this time, I was told to call "again" because on February 5th 2010 UPMC stopped covering the VSG. This was confirmed by the Surgeon and his PA. I appealed. But of course my appeal was denied and I have no proof. Has anyone had a similar experience with UPMC and/or has anyone had the VSG procedure under the UPMC Plan? I am appealing to change my plan from UPMC to Blue Cross of Illinois who is approving the VSG.

Hey

I was just denied last week for BCBS of Illinois because their procedure has not changed and VSG is still "experimental and investigational". Do you know something that I do not? I am in the process of writing up my appeal in an attempt to reverse their decision. Once they saw that I was asking for the VSG code 43775 - it was an instance "no". Has anyone been successful winning an appeal with BCBS of Illinois?

Lou

Hi

My first post on this board ...

I have my first appointment with Dr. Radulescu on Monday March 22.

I was working with another doctor in the Orlando area? but when I challenged his staffs ability to process my insurance claim (which was denied because the way it was submitted? another story)? he dropped me.. I?m sure that is a blessing in disguise.

The Lap-Band was what I was going for,,, but had lunch with an old friend yesterday and now I am full steam ahead for the sleeve.

I was setup with the nutritionist in Dr Radulescu?s office by the other doctor?s office and was very impressed with her knowledge and the good things she said about this office. After talking to the office manager and setting up my first appointment ? it is night and day better then the first doctor?

Saying that ? if interested ? I can report back after my visit.

Lou

Thanks all for your support. I now have an appointment with a new office - one that seems a lot more organized. Talking to BCBS myself - I now know exactly what is needed to get my approval - all of which was already sent to them but not in away that summarizes and shows them on the cover letter why I should be approved. I go next Monday and hopefully will get thing moving again.

Just to put icing on the cake.... the previous doctor sent me a letter saying he was not my doctor anymore - and the office was so efficient they put a "blue card" on the letter to make it so I would have to sign for it but forgot to check to "signature required" box ...

Like some of you said - it was a blessing in disguise to find out before the procedure, the quality of service and expertise in the office.

I would wager to say that the doctor is probable ok - it is his office staff that messed thing up which he is probable not aware of...

Lou

This is my first posting… and I’m sure not my last.

I was going to wait until I was banded – but that has been put on hold.

My story…. I as many of you have, did a bunch or research and committed in my mind that this was what I needed. It was a very hard decision as I am really addicted to food, my diabetes is getting worst and weight going up. The first step was to find a doctor close by that was accepted by my BCBS. Found one that was the husband of my wife’s doctor who has been great for her. I went to his seminar and setup an appointment the next week. As I did my homework, I brought a bunch of stuff with me to this appointment including the requirements that BCBS insisted on and all my information on my recent 1 year on Weight Watchers. My first appointment really gave me a bad taste for this practice - I did most of the talking and tried twice to give this information to the "assistances" but told they did not need them because they worked with insurance all the time and had their own. I was never sat down and talked to - just given their requirements like make my own appointment with the nutritionist and they would setup one for the psychologist.

I completed both of these, got/gave them the required letter from my doctor along with over one inch thick copy of my doctor's file that dated back to 2002. I even went as far as compiling a cover sheet as I reviewed every page from the doctor notes of my weight, BP, AIC and cholesterol reading.

So at this point I thought it was a slam dunk - I am 60, weight 265 so BMI = 38 and insulin dependent diabetic.

Wrong - I called BCBS and was rejected after 2 weeks. Reason - the doctors office did not follow their requirements. Since my BMI was under 40 - I had to qualify by having 2 of 6 listed "comorbid conditions". Well I had 1 - Diabetes - but no mention or suggestion of any other. They also needed more information about my 1 year on WW.

When I called the doctor's office really discussed - they apologized for not doing the "required stuff" and would talk it over with the doctor and call me back. The next morning the office manager called me back and said that the doctor was dropping me and by the way - he found 3 "comorbid conditions" after reviewing my records (if he had found them before and did his job the way he should have - I would have a scheduled surgery date my now).

So I am very discussed - all that work, all that hope, all the time and money spent to get to my goal. As I said, I am 60 and want to live a long time. My daughter and her 2 sons (4 & 6) live with us now and I really want the health and energy to enjoy them and them to enjoy me...

I have not given up. I did a bit more research and found another doctor's office (the one that I meet with the nutritionist) and they are to call me back today.

Sorry for the long post - just had to get it out there...

Lou