Lap_dancer

Tracy you're on your way. Very close to be sure. .......... My Appeal was denied. My next option is to go to the state review. I will, what have I got to lose? I will speak to employee benefits tomorrow. Today is a sad day for me.

Congratulations on your surgery although you aren't feeling very chipper right now. I agree that finding a support group in your area would most likely help. Until then, stick to reading these bulletins. The people here are very understanding, resourceful and easy to access (the web!). I would call your doctor about the nausea. I am not banded, I am so envious. How I wish I was past the surgery and in the recovery phase and going down. My best to you.

:whoo::whoo::whoo::whoo::whoo::whoo::whoo::whoo: THIS IS AWESOME!!!!!!!!!!!!!!!!!!!!!!!!!!!! YAYAYYAYAY I am beyond happy for you. (goosebumps) Tracy is next. C'mon girl. Let's hear the good news!!!! My meeting is tomorrow for the Appeals. Think powerful thoughts!

See this is the part that scares me. While Sparadiso8116 is covered... TerrilenI currently have United health Care and by the grace of God all my Lap Band needs have been covered. I am on social security disability and in Febuary finaly qualify for Medicare. My question is....does anyone else have Medicare and does it cover care associated with your band? Thanks alot!:welldone: Terrilen is not. Wow. I am seeing more and more of this select and choose method of coverage which tells me one thing, we all need to know more about our insurance than the people that work at our insurance companies.

Hi Len: First, congrats Tampa girl for the great amount of loss. Way to go! I think what you should do Len is do what is right for you. There are many procedures and like Tampa said, all of them have drawbacks. I looked into all of the current procedures available. Although my doctor suggested a gastric bypass, I am for the Lap Band. I was not excited about getting my organs cut, staples. It was just something I did not want to do. The Lap Band's most recent studies showed improvements in it such that recovery time was less, maintenance was a big concern for me but there is support at my hospital. There is also a procedure once you are at goal and have reconstructive surgery to remove the apron if you happen to have that problem post your weightloss. They can adjust the band at that time so it is less visible. But I agree 100% with Lori, think of life after the band and ask yourself are you the type of person that could fit this into the mainstream of your life. Best of luck.

In searching this forum you may find the topic you are looking for or the question you want to ask already posted. A quick feature is the "Jump Forum JUMP option at the bottom of the page. Scroll down and you will see the FORUM JUMP option on the right. Click and the box will open up. If you have a question related to insurance, click there, refills, click there, and so forth. The Private message feature at the top of the page on the right allows you to contact a member privately. You can also utilize PM by going to their user name at one of their posts, clicking on it and at the drop box, select Send Private Message. Hope this helps.

I keep seeing the appearance of the words "Centers of Excellence" for insurance coverage of Lap Banding. This is what I found for Medicare: Medicare has made a landmark decision to cover the gastric bypass and LAP-BAND® procedures for patients meeting specific criteria (see below). Coverage will be approved only when care is delivered by surgeons and facilities that have received the ASBS (American Society for Bariatric Surgery) "Center of Excellence" designation. ASBS designated Dr. Johnell and North Colorado Medical Center as a Center of Excellence on October 28, 2005. Our program immediately qualifies for Medicare coverage. To find out if you qualify for bariatric surgery and for more information, please read below! The Centers for Medicare & Medicaid Services (CMS) has determined that the evidence is adequate to conclude that open and laparoscopic Roux-en-Y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), and open and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS), are reasonable and necessary for Medicare beneficiaries who have a body-mass index (BMI) > 35, have at least one co-morbidity related to obesity, and have been previously unsuccessful with medical treatment for obesity. CMS has determined that covered bariatric surgery procedures are reasonable and necessary only when performed at facilities that are: (1) certified by the American College of Surgeons (ACS) as a Level 1 Bariatric Surgery Center (program standards and requirements in effect on February 15, 2006); or (2) certified by the American Society for Bariatric Surgery as a Bariatric Surgery Center of Excellence (BSCOE) (program standards and requirements in effect on February 15, 2006). To view Medicare's decision memo dated February 15, 2006, please click on the following link: http://www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=160 The next step for me would be calling my doctor. The insurance secretary would be the one who could tell you, however if they said NO, it could be because you don't meet the criteria which is listed above.

:omg: Projectile? Hope that projects into the right place!:nervous "As seen on Oprah" kicks it for me.

:hungry: I'll bite. (which isn't hard at all for me to do) First, happiness and well wishes your way on safely coming home to you and hubby. My future son-in-law is in the military and I'm just now getting acclaimated to the whole military lifestyle. The acronymns are about to make me crazy. My biological family puts the D in dysfunction. My grandmother was bulimic, my mother, my sister and I did the opposite eating my way to a 61 BMI. Think anyone talked about it? On my father's side my grandfather committed suicide at 38. He has PSD from the war which they "treated" with electric shock therapy. No one talked about his suffering either. The only way I learned about it was a long road trip where I was driving and grandmother was a passenger. You raise a solid point about those enablers. I think they don't know how to address it or choose not to. I sometimes wonder if my husband is waiting for me to kick the bucket so he can get on with his life. Since I put on the last 50 pounds our formerly active sex life has hit the skids. It seems like it doesn't bother him at all. It hurts to think that he has no desire for me. I'm always hugging him and teasing him and he smiles but there is nothing returned. THIS really depresses me. My body image depresses me. I find times when I am LOW. Can't think of one positive thing to be grateful for. I am on medication therapy but I would not take my own life. I've seriously thought about it but the guilt I have felt from what it would do to my children put a stop to any further thoughts.

Hi tachlime. Welcome and congratulations on getting approved so quickly.

Hey Courtney! Post back if you have any questions or private message me. It's almost like my walk in life since 1995 has been to prepare me for this moment in dealing with my own insurance battle. (and I'm fighting for my life). So many people on here have the same fight too! Isn't that crazy? it's like there is an industry around the fat population that is making loads of money while we die and they just don't seem to want to lose that $ource. (yeah, that one was a little paranoid but makes me wonder sometimes) Good luck and keep me posted.

Noticed they actually identified the Lap-Band by brand. Interesting.

I've been doing my own research for BCBS and have saved my finds in a thread I started. (it's just so much information) Here is criteria I found: DESCRIPTION: Clinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. For purposes of this medical coverage guideline, clinically severe obesity is defined as a body mass index (BMI) of 35 kg/m2 or greater. See the height and weight tables for Men and Woman, BMI tables (100-195, 200-295, 300-400, and formula for calculating a BMI. Several surgical (bariatric) procedures are used for the treatment of clinically severe obesity. These procedures can be categorized as follows: <LI class=bulletedList-1>Malabsorptive procedures - alteration of the intestinal absorption limiting nutrients available to the body OR Gastric restrictive procedures - reduction in the capacity of the stomach thereby limiting the amount of food ingested. Gastric surgical procedures for the treatment of clinically severe obesity include: <LI class=bulletedList-1>gastric bypass where approximately 90% of the stomach is bypassed and reattached to the proximal jejunum OR gastric stapling, vertically banded gastric partition, or vertically banded gastroplasty where a proximal pouch of 30-60 ml and a one centimeter outlet are created by a row of vertical staples and a horizontally placed reinforcing band Certain surgical procedures performed for the treatment of clinically severe obesity may be considered medically necessary when ALL of the following conditions are met: The member: meets the above definition of clinically severe obesity,has been severely obese for at least five (5) years, has attempted a physician supervised (by the primary care physician) non-surgical management weight loss program (e.g., diet, exercise, drugs) for six (6) consecutive months ,has received psychological or psychiatric evaluation with counseling as needed, prior to surgical intervention; does not have a medically treatable cause for the obesity, (e.g., thyroid or other endocrine disorder). The following procedures may be considered medically necessary when the above criteria has been met: http://mcgs.bcbsfl.com/index.cfm?fuseaction=main.main&doc=Surgery%20for%20Clinically%20Severe%20Obesity

Good thoughts here.

I was simply searching Blue Crosses website and found this! http://www.bcbs.com/betterknowledge/tec/press/ Technology Evaluation Center in the Press November 2006 The following Assessments and Special Reports were acted on at the November 2, 2006, Blue Cross and Blue Shield Association Medical Advisory Panel (MAP) meeting: Laparoscopic Adjustable Gastric Banding for Morbid Obesity The MAP concluded that laparoscopic adjustable gastric banding for morbid obesity meets the TEC criteria, when performed in appropriately selected patients, by surgeons who are adequately trained and experienced in the specific techniques used, and in institutions that support a comprehensive bariatric surgery program, including long-term monitoring and follow-up post-surgery.

Still rolling and storing data and sites: http://mcgs.bcbsfl.com/ Medical guidelines ( criteria to meet) for BCBS Medical codes and diagnostic codes Subject: Gastric Bypass Revision http://mcgs.bcbsfl.com/index.cfm?fuseaction=main.main&stage=pub&format=cfm&doc=Gastric%20Bypass%20Revision#P24_1042 DESCRIPTION: In cases where a severe, potentially life threatening condition develops which is documented in the medical record, gastric bypass revision is considered medically necessary and may be eligible for coverage. WHEN SERVICES ARE COVERED: The following lists examples of conditions AND/OR diagnoses for which gastric bypass revisions may be covered: <LI class=bulletedList-1>Weight loss of 20% or more below the ideal body weight (based on the 1996 Metropolitan Life Height & Weight tables Men and Women) <LI class=bulletedList-1>Esophagitis (e.g., esophageal reflux) <LI class=bulletedList-1>Hemorrhage or hematoma complicating a procedure <LI class=bulletedList-1>Vomiting (bilious) following gastrointestinal surgery <LI class=bulletedList-1>Gastrointestinal complications, (i.e., complications of intestinal (internal) anastomosis and bypass) <LI class=bulletedList-1>Stomal dilatation, documented by endoscopy (not UGI) <LI class=bulletedList-1>Pouch dilation documented by upper gastrointestinal examination or endoscopy, producing weight gain of 20% or more <LI class=bulletedList-1>Stomal stenosis after vertical banding, documented by endoscopy, producing vomiting or weight loss of 20% or more <LI class=bulletedList-1>Other and unspecified post surgical nonabsorption (i.e., hypoglycemia and malnutrition following gastrointestinal surgery) <LI class=bulletedList-1>Other post-operative functional disorders (i.e., diarrhea following gastrointestinal surgery), <LI class=bulletedList-1>Severe dumping syndrome <LI class=bulletedList-1>Post-gastric surgery syndromes (i.e., post-gastrectomy syndrome, post-vagotomy syndrome) <LI class=bulletedList-1>Disruption of operation wound <LI class=bulletedList-1>Staple line failure, documented by upper gastrointestinal examination Disrupted staple line provided there has been prior weight loss. WHEN SERVICES ARE NOT COVERED: Gastric bypass revision services are not covered when coverage criteria are not met as described in the WHEN SERVICES ARE COVERED section or when the member's contract does not provide benefits for these services. BILLING/CODING INFORMATION: http://mcgs.bcbsfl.com/index.cfm?fuseaction=main.main&stage=pub&format=cfm&doc=Gastric%20Bypass%20Revision#P24_1042 CENTERS for bariatrics BCBS To Your Health Distinction Centers http://www.fepblue.org/toyourhealth/tyhbdistincentindex.html HIPAA regulations from BCBS http://www.fepblue.org/privacyhipaa/hipaareg_mov.html Federal Employee Program BCBS http://fep.careenhance.com/portal/index.jsp

01/01/06 Annual HCPCS coding update (revise 43848; add 43886, 43887, and 43888. Additional coding for BCBSFL

and more............ http://mcgs.bcbsfl.com/ THIS MEDICAL COVERAGE GUIDELINE IS NOT AN AUTHORIZATION, CERTIFICATION, EXPLANATION OF BENEFITS, OR A GUARANTEE OF PAYMENT, NOR DOES IT SUBSTITUTE FOR OR CONSTITUTE MEDICAL ADVICE. ALL MEDICAL DECISIONS ARE SOLELY THE RESPONSIBILITY OF THE PATIENT AND PHYSICIAN. BENEFITS ARE DETERMINED BY THE GROUP CONTRACT, MEMBER BENEFIT BOOKLET, AND/OR INDIVIDUAL SUBSCRIBER CERTIFICATE IN EFFECT AT THE TIME SERVICES WERE RENDERED. THIS MEDICAL COVERAGE GUIDELINE APPLIES TO ALL LINES OF BUSINESS UNLESS OTHERWISE NOTED IN THE PROGRAM EXCEPTIONS SECTION. Non-Covered Billing/Coding Reimbursement Program Exceptions Definitions Related Guidelines Other References Updates DESCRIPTION: In cases where a severe, potentially life threatening condition develops which is documented in the medical record, gastric bypass revision is considered medically necessary and may be eligible for coverage. WHEN SERVICES ARE COVERED: The following lists examples of conditions AND/OR diagnoses for which gastric bypass revisions may be covered: <LI class=bulletedList-1>Weight loss of 20% or more below the ideal body weight (based on the 1996 Metropolitan Life Height & Weight tables Men and Women) <LI class=bulletedList-1>Esophagitis (e.g., esophageal reflux) <LI class=bulletedList-1>Hemorrhage or hematoma complicating a procedure <LI class=bulletedList-1>Vomiting (bilious) following gastrointestinal surgery <LI class=bulletedList-1>Gastrointestinal complications, (i.e., complications of intestinal (internal) anastomosis and bypass) <LI class=bulletedList-1>Stomal dilatation, documented by endoscopy (not UGI) <LI class=bulletedList-1>Pouch dilation documented by upper gastrointestinal examination or endoscopy, producing weight gain of 20% or more <LI class=bulletedList-1>Stomal stenosis after vertical banding, documented by endoscopy, producing vomiting or weight loss of 20% or more <LI class=bulletedList-1>Other and unspecified post surgical nonabsorption (i.e., hypoglycemia and malnutrition following gastrointestinal surgery) <LI class=bulletedList-1>Other post-operative functional disorders (i.e., diarrhea following gastrointestinal surgery), <LI class=bulletedList-1>Severe dumping syndrome <LI class=bulletedList-1>Post-gastric surgery syndromes (i.e., post-gastrectomy syndrome, post-vagotomy syndrome) <LI class=bulletedList-1>Disruption of operation wound <LI class=bulletedList-1>Staple line failure, documented by upper gastrointestinal examination Disrupted staple line provided there has been prior weight loss. WHEN SERVICES ARE NOT COVERED: Gastric bypass revision services are not covered when coverage criteria are not met as described in the WHEN SERVICES ARE COVERED section or when the member's contract does not provide benefits for these services. BILLING/CODING INFORMATION: CPT Coding: 43848 Revision , open, of gastric restrictive procedure for morbid obesity, other than adjustable gastric band (separate procedure) 43850 Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; without vagotomy 43855 Revision of gastroduodenal anastomosis (gastroduodenostomy) with reconstruction; with vagotomy 43860 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; without vagotomy 43865 Revision of gastrojejunal anastomosis (gastrojejunostomy) with reconstruction, with or without partial gastrectomy or intestine resection; with vagotomy 43886 Gastric restrictive procedure, open; revision of subcutaneous port component only 43887 Gastric restrictive procedure, open; removal of subcutaneous port component only 43888 Gastric restrictive procedure, open; removal and replacement of subcutaneous port component only ICD-9 Diagnoses Codes That Support Medical Necessity: 530.1 Esophagitis (esophageal reflux) 536.1 Acute dilatation of stomach (documented by endoscopy, not UGI) 536.1 Pouch dilation (documented by UGI or endoscopy; producing weight gain of 20% or more) 537.6 Stenosis of stomach (after vertical banding documented by endoscopy; producing vomiting or weight loss of 20% or more) 564.2 Postgastric surgery syndrome (i.e., post-gastrectomy syndrome, post-vagotomy syndrome, severe dumping syndrome) 564.3 Vomiting following gastrointestinal surgery 564.4 Other post-operative functional disorders (i.e., diarrhea following gastrointestinal surgery) 579.3 Other and unspecified postsurgical nonabsorption (i.e., hypoglycemia, malnutrition following gastrointestinal surgery) 783.2 Abnormal loss of weight (20% or more below the ideal body weight according to the 1996 Metropolitan Life Height & Weight tables for men and women) 997.4 Digestive system complications (i.e., complications of intestinal (internal) anastomosis and bypass) 998.11-998.13 Hemorrhage or hematoma complicating a procedure 998.3 Disruption of operation wound (i.e., dehiscence; rupture; staple line failure documented by upper gastrointestinal examination; disrupted staple line, provided there has been prior weight loss) REIMBURSEMENT INFORMATION: Refer to section entitled WHEN SERVICES ARE COVERED. PROGRAM EXCEPTIONS: Federal Employee Program (FEP): Follow FEP guidelines. State Account Organization (SAO): Follow SAO guidelines. DEFINITIONS: No guideline specific definitions apply. RELATED GUIDELINES: Surgery for Clinically Severe Obesity (Bariatric Surgery; Gastric Bypass Surgery), 02-40000-10 OTHER: To view the Metropolitan Life Height & Weight tables Men and Women, see Surgery for Clinically Severe Obesity (Gastric Bypass), 02-4000-10. REFERENCES: <LI value=1>American Medical Association CPT (current edition) <LI value=2>Florida Medicare Part B Local Medical Review Policy # 11920: Cosmetic/Reconstructive Surgery (01/01/02, retired 02/01/04) <LI value=3>Florida Medicare Part B Local Medical Review Policy # 40000: Digestive System (01/01/02) <LI value=4>Medical Practice and Coverage Committee (BCBSF) St. Anthony’s ICD-9-CM Code Book (current edition) COMMITTEE APPROVAL: This Medical Coverage Guideline (MCG) was approved by the BCBSF Medical Policy & Coverage Committee on 09/23/04. GUIDELINE UPDATE INFORMATION: 10/15/99 New Medical Coverage Guideline. 01/01/02 Coding changes. 12/15/02 Reviewed; typographical corrections. 10/15/04 Scheduled review; no change in coverage statement; added 43848. 01/01/06 Annual HCPCS coding update (revise 43848; add 43886, 43887, and 43888. Private Property of Blue Cross and Blue Shield of Florida. This medical coverage guideline is Copyright 2006, Blue Cross and Blue Shield of Florida (BCBSF). All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission of BCBSF. The medical codes referenced in this document may be proprietary and owned by others. BCBSF makes no claim of ownership of such codes. Our use of such codes in this document is for explanation and guidance and should not be construed as a license for their use by you. Before utilizing the codes, please be sure that to the extent required, you have secured any appropriate licenses for such use. Current Procedural Terminology (CPT) is copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. CPT® is a trademark of the American Medical Association. Internet Privacy Statement | Terms of Use © 2006 Blue Cross and Blue Shield of Florida, Inc. Date Printed: January 5, 2007: 10:48 PM

Oh yeah. I'm there with the naughty clothes. I want to: Buy lace in Belgium. Buy silk in Hong Kong. Buy pearls and jewelry in Beijing, China. Buy opal jewelry in Australia. Body surf in California. Dive off the Great Barrier Reef in OZ Run the highway that leads to Devil's Tower, Wyoming. Ski in Aspen, Colorado. Attend Burning Man with my nieces in Nevada. Attend Glastonbury Music Festival in the U.K. (and Cardiff, Bestival on the Isle of Wight) My goal is to LIVE. At the moment my weekends are spent observing or laying on my bed. Moving for me is most painful.

Here's what I would do and why. Call the number on your card regarding customer service. Customer service will ask for all your numbers, blah blah blah, you act like you are calling in a pizza. Finally you say: "Okay, I'd like to check on the status of my authorization I was told it would be up to a week and it's been about a week." or "my surgeon's office is scheduling and I need to plan time off with work and secure a date" ( the average Joe can relate to this) ..there is just a sense of urgency in not waiting and in proceeding on. If you are the type that gets nervous on the phone, write down what you will say like this: If they say: "We don't have that information" You say... "Okay can you connect me with who does have that information?" If they say: "We still don't have an answer" you say..." Okay can I speak to a supervisor please" Customer service is the entry level. Remember, this is YOUR health insurance that you pay for. That person is only doing intake and if they don't have your answers their job is to find the correct department that does. Keep a call log of who you spoke to and what time and what date. If they don't have anything for you and tell you to call back in a few days, call back in a few days and say Yes I spoke to Margie on January 4th at 11 PM Eastern and she told me to call the center today to check on my authorization number.

Clear as mud! (not really but clear at any rate) Sounds like they want it from horse's mouth. Fine. Thanks for the quote. I just need to see that for myself in my own benefits package. Do you know criteria for exclusions being reconsidered and determined necessary as in medically necessary so it gets approved? THAT is the language I need to see. You are close. I think by next week you will see some determination and authorization your way. I can see where they would want authorization number to process, that seems a norm anymore. Like you need a ticket to get into the show and a stub to get back in.

100 lbs overweight. You must be experiencing, shortness of breath, backpain, joint pain, difficulty sleeping, depression ( maybe not but this applies to me and I can definately tie it to my obesesity), my sex life was impacted which effected my husband. That is a lot of extra weight to carry but some people do it without any adverse effects.

TracyinKS I've been watching your case but not posting. I'm now posting. You're right there I can feel it. I can only add that I wrote a letter of impact myself. My BMI is (in a dream last night it was written in white, 61, on a red placemat. Anyone do dream interpretation???? I called BCBS and asked for my SPD, I want a copy so I can look for loop holes. When I asked Customer Service for a copy, she acted like she had no idea what I was asking for. She said they didn't have access to that. I took it to the next level. This person did the same thing. She told me to contact my employer. A friend of a friend told me that we have a legal right to our SPD's. True? What's up with that. So quick question is there a claus for medical necessity? I love your grit.

Hey skinnymom I'm glad it was just a bug and nothing real serious. Do keep updates here on your progress. Congratulations!