has anyone had any luck with getting aproved for VSG with BCBS TX is so how did you do it or how and who would I contact to work on this:confused1:

Hi. I have been watching this post since Monday and see that there are still no responses. I also have BCBS TX and am wondering about approval for VSG.

I am just beginning this process and hope to have Dr. Nick in Plano do my surgery. When I talked to the ladies in his office on 2/1/10, they said that they have not had any approvals from BCBS TX for VSG this year. They acutally had two denials in January and are appealing now. They did say they had several VSGs approved by them last year...so.....who knows??

I know this is not what anyone wants to hear (including me!)...but I thought I would share what info I have.

The nice ladies at Dr. Nick's did say that they are sure they can make "something" happen! I've got my fingers crossed!

I hope others will post any recent info they have on BCBS and VSG approval.

Edited February 5, 201016 yr by thintopia
added date

Hi there.

I too have BCBS, but I have BCBS Federal, however I hear they go by what state you're in and I live in Texas. I'm getting nervous. I have my appt with the surgeon and ins coordinator on Feb 25. I promise I'll report back when I learn something.

Good luck to everyone!

-Nicole

Hi all. I got a a letter from Dr. Nick's office about the verification of my BCBS TX benefits and their requirements for approval.

The following is the ACTUAL text from the letter about the verification of my benefit and what BCBS requires... hope this helps someone.

This is not an approval letter from your insurance company. This is a letter to notify you of criteria your insurance company

requires of you. Please read through this letter's entirety.

Thank you for your interest in the Weight Loss Surgery Center at Baylor Regional Medical Center at Plano. This letter is to inform you

that your insurance carrier, Blue Cross Blue Shield of Texas, has approval criteria for weight loss surgery. The Medical Review

department has made it very dear that all requests for weight loss surgery must adhere to their requirements precisely or they will not

consider the request. As a result, you will need to obtain the following documentation:

1. Medical record documentation of active participation of a doctor supervised, non-surgical program for at least 3 months.

occurring within the past 24 months and preferably unaffiliated with the bariatric surgery program. This means 3 monthly

visits with your PCP or a registered dietitian and will include the following:

• Nutritional therapy. which may include medical nutrition therapy such as a very low calorie diet such as

Medifast. or a recognized commercial diet-based weight loss program such as Weight Watchers or Jenny

Craig.

• Behavior modification or behavioral health interventions.

• Counseling and instruction on exercise and increased physical activity.

• Pharmacologic therapy (as appropriate),

• Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk

factors and improve overall health.

2. Psychological evaluation and clearance by a licensed mental health professional within the 12 months preceding the request

for surgery.

3. Per recent ASA (American Society of Anesthesiologists) recommendations, a pre-operative sleep study is required to assess

for possible obstructive sleep apnea. This diagnosis is very important in assisting our anesthesia team in providing optimal

care. Furthermore, a diagnosis of obstructive sleep apnea is frequently a major determinant as to whether or not one qualifies

for bariatric surgery. This is one of the most common disease processes associated with morbid obesity. You will be required

to have this diagnostic test prior to surgery. This requirement also remains in effect even in patients already with a diagnosis of

sleep apnea under the following circumstances: Greater than one year from a previous sleep study or a weight loss/gain

greater than 15 lbs since the time of your last sleep study.

We understand that this situation seems frustrating and time consuming. but please know that our office is here to help you during this

process. Once you have obtained the necessary records, please mail or fax them to our office to my attention. A Letter of

Medical Necessity along with your documentation will then be sent to Blue Cross Blue Shield of Texas.

**You may want to take a copy of this letter to your physician(s) and see what they can assist you with.**

EDIT: Spoke to Dr. Nick's office today, 2/15/10...the three months of supervised weight loss treatment required by BCBS TX must be three CONSECUTIVE months!

Edited February 16, 201016 yr by thintopia
clarification

thintopia-

wow! I have never heard those requirements from BCBS before, did you double check that with the insurance company?

-Nic

Nic,

Honestly, no. I did not double check by calling BCBS myself. I was just going with what Dr. Nick's office said since they work specifically with the insurance companies all day long...and I'm sure they would want their patients to jump through any unnecessary hoops.

Perhaps I will call....

Have you heard something different from them?

Thanks!

I have done all that but for 6 month period not 3 month and was still told it is not covered

Just for clarification, I have BCBS of Texas. It is not federal or for any other state.

My benefit has been verified. That means that, yes, BCBS of TX DOES cover the VSG and HAS verified that with my doctor's office.

They have listed out the requirements for approval.

Yathink, I do not understand why BCBS would say "it is not covered" if you have the benefit on your plan. Perhaps they meant "you are not approved" for whatever reason...which they should have stated in their denial letter.

thintopia the denial letter they sent me said it is not corporatly covered so I witch I am not sure what that means, and I also spoke to my Head Of HR today and she is doing some checking because she dont under stand the denied me for bypass to and she said that there is other people working for the company that has had it done so hopefully I'll get some news soon.

I dont know if they are giving me a hard time because I'm in DE. with BCBS TX because that is were our home office is or what.

Are you sure your company covers ANY weight loss surgery. Many companies don't buy the extra coverage for WLS. Have them send you your policy on WLS.

It sounds like by the denial reason that the company/corporations has excluded WLS as a covered service. It is something that is becoming more and more prevalent among big corp insurance policies because their rates go up substantially for surgeries.

This is why we are seeing so many companies giving incentives for weight loss, non-smoking, having breast exams/pap smears, and prostate exams done as preventative health care.

It's absolutely horrible because they don't exclude heart bypass surgery for all the fat employees which cost 3-4 times as much as WLS, but they figure only 1 out of5 people will need heart bypass instead of 20 out of 20 fat employees will want WLS covered which in the long run will cost the corp more money in premiums.

weekendwarrior, I have spoke to my HR and BCBS my company didnt opt out for WSS when I spoke to BCBS they told me the band (which my Dr. said no) and ByPass (which I.m saying no) are covered, if aprooved so dont even have a deff on it.

Tiffykins; thats what I got out of the letter and the women from BCBS but when my HR department checked into it they were told its still experimental so I'm lost and runing out of steam I have been working on this now for a year.

I have BCBS North Dakota through my hubby's employer, but we live in Oregon. They have a pilot program where they are starting to cover VSG. The catch is that you have to have the procedure done at a "Blue Center of Distinction", in North Dakota. I am hoping that by the time I get all the requisite stuff done, they will allow me to have my procedure at our local center of distinction, which is also a Center of Excellence, in Boise, Id. I am not in a position to travel from here to North Dakota, with all of the after care that is required.

weekendwarrior, I have spoke to my HR and BCBS my company didnt opt out for WSS when I spoke to BCBS they told me the band (which my Dr. said no) and ByPass (which I.m saying no) are covered, if aprooved so dont even have a deff on it.

Tiffykins; thats what I got out of the letter and the women from BCBS but when my HR department checked into it they were told its still experimental so I'm lost and runing out of steam I have been working on this now for a year.

Can you get a copy of your policy?