OK.....I work for CareFirst BlueCross BlueShield. I was told by our member services that the Sleeve was covered. I also looked at a copy of our Medical Policy, which states:

Sleeve gastrectomy, performed either as a stand-alone restrictive procedure, or as a first stage procedure of a planned biliopancreatic bypass with duodenal switch for patients with a BMI exceeding 50

So, assumed that since I was just having a stand-alone restrictive procedure, there was no BMI associated with that. However, it appears that CF will only cover the sleeve for patients exceeding 50. This makes no sense to me.

I'm ready to throw-up and cry!

I do not want the bypass. If I appeal, my date of 11/10 is out the window. :confused:

Thanks Mountain_Lover!

I was told that I would have a decision by tomorrow (Monday). If my appeal is denied, then that will be it, with no other options of appeals, since I am in a self-insured account. I already have been in contact with a coordinator for Dr. Almanza, and scoped out airfare (just in case.....for my own sanity, I need to have a backup plan in place to immediately act on).

So tomorrow you will be reading YaaaaHooo, I'm been approved, or Ole going to Mexico!

Mountain_Lover, I wish you a speedy approval on your insurance. I know how hard this waiting game is.

Thanks to everyone on this forum for your support. It has made these last 3 weeks much easier on me!

Hugs to All,

JoAnne

We will be awaiting your response - either way - since you have a back-up plan - you're going to get your surgery and your life back - it's a win-win situation in the long run.

A back up plan is a great idea. I was almost glad that my insurance would not cover my sleeve...that meant I could just do it without any wait or hassles. Luckily I had been saving up the money.

There is a quick test done on CT that looks at the heart for blockages and in my area costs $99. It is another good check for heart and of course you will get radiation but a simple test.

Decision on my appeal has been denied. I am told it is not Medically Necessary.

Enough said. I have no recourse.

I will focus on next steps.

Thanks all for your support during this trying time!

Hugs to All,

JoAnne

OMG! I'm so sorry to hear this! I hate it when insurance companies resort to a play on words, like in this case, to deny a claim! It's just NOT fair!

Hang in there jsm, it WILL happen for you!

I'm sorry JoAnne. I know how you feel. My insurance also denied my claim for sleeve surgery. They would pay for by-pass or band only.

I decided to self pay and get on with my life.

Good luck in whatever decision you make.

I'm really sorry the appeal was denied. I hope you are able to make arrangements for you to get your surgery date ! ! ! We're all pulling for you and your future success.

Now that the only alternative is to go to Mexico, I'm getting a lot of opposition.

1. Should something go wrong with the surgery, finding a local surgeon will be next to impossible. (got this from my surgeons office)

2. After Care follow-up will be next to impossible to find.

2. Husband is against me going to Mexico due to the above.

I feel so screwed over. Even If I cave in to RNY, my surgeon knows how dead set I am against it, and may not do it since my head is not in the best state for a surgery that I don't want.

Now that the only alternative is to go to Mexico, I'm getting a lot of opposition.

1. Should something go wrong with the surgery, finding a local surgeon will be next to impossible. (got this from my surgeons office)

2. After Care follow-up will be next to impossible to find.

2. Husband is against me going to Mexico due to the above.

I feel so screwed over. Even If I cave in to RNY, my surgeon knows how dead set I am against it, and may not do it since my head is not in the best state for a surgery that I don't want.

99.9% of the time, the what ifs never happen....they are equipped at the hospital where you are being sleeved to take care if something goes wrong at the time. Your PCP will likely take care of you should you need a prescription or to check you over if things are not going the way you think they should. No after care other than that is needed, this is a very simple surgery. My daughter was dead set against me going to Mexico at the beginning too, but I chose it anyway, my body, my destiny! Now she is going to get her sleeve in Mexico at the same facility in January!

Fear mongering is just that, mostly from ignorance!

If you can find your way to borrow $5000 or so, check out my choice in Mexico, most affordable one out there, and most everyone who goes there is happy with the surgeon and the facilities. Or you can pay almost double that and go to Mexicali and you will be happy with that choice too.

Don't let people sway you from getting the sleeve, it is the easiest, least complications, and works if you do the work too!

Cheers,

Donna:001_cool:

I'm sorry to hear that your appeal got denied.

I'm gonna say a few things that might not be so popular with everyone here.

I am a self pay for the sleeve, because my insurance had no benifits for weight loss surgery of any kind. I chose the sleeve because, frankly, it was cheaper, but I did like everything about it. I was SEVERLY overweight. I actually thought I needed the DS. So the sleeve was my choice because it was the first part of the DS.

But I can say this, IF my insurance would have paid for the RNY- I would have done it. Mainly because I KNEW I had to do something to improve the quality of my life. And if they would have paid......I would have let them!

I hadn't even heard of the doctors in Mexico, and not sure if I would have done that because I would have to have done it alone, and wouldn't want to go there alone.

I hope things work out for you, your in my thoughts.

Joanne -- sorry that your appeal was denied - that is so unfair. I hope that you are able to secure an alternative and we'll be here to support you in whatever your decision may be.

I still may have a shot for approval!

OK, after I regrouped yesterday, I spent several hours digesting the content of my denial.

To my surprise I found two major flaws in their decision. 1) As I had referenced in my appeal, our medical policy on Sleeve Gastrectomy was extracted from a 2007 position paper from the ASMBS. The ASMBS "Executive Council has removed that outdated statement and has charged the Clinical Issues Commitee to review current data and revise the position statement".

http://www.asmbs.org/Newsite07/resources/sleeve_statement.pdf

I questioned, "How a denial could be made based on our Medical Policy where the source of the information can no longer be referenced?"

2) In my appeal, I also referenced "A systematic review of the literature covering Sleeve Gastrectomy through January 2009 which was published in June this year." This literature contained 36 studies with over 2500 patients. I knew for a fact that this study was never reviewed as part of my appeal, since I had to pay for a copy of this paper. (if anyone would like a copy of this literature for your own investigation, please PM me with your email address).

I emailed Central Appeals with my above concerns (along with the soft copy of these documents), and requested a re-review based on the above.

I received notification late this afternoon that the Medical Director has agreed to review the 2009 literature I provided, and will render his decision by next Tuesday.

I feel my odds of approval are 50 - 50, since the Medical Director could have refused to reconsider my appeal after the denial was rendered.

Please keep your good thoughts and prayers coming!

Hugs,

JoAnne

JoAnne that is great news. There is hope after all. I'm praying for you.:crying:

Ohhhhhhhhhh JoAnne that is good news. Sending you good vibes for even better news next week.