Anyone know anything about Wellmark/BCBS in Iowa and where they are as far as covering the sleeve? I heard that it was in committee. It seems that BCBS in other states is covering.....

It's still considered investigational according to their current policy.

Here's a link to their policy.

Bariatric Surgery for Morbid Obesity*

I have also heard they are currently reviewing their policy. I am hoping they join all of the other companies that are covering it. I am pretty sure they will as it saves them money in the long run.

I started my 6 month diet last month. I am still unsure if a full 6 month supervised diet is required as I have had conflicting information. I've called wellmark 3 times and never get the same answer twice in a row.

I did find a form the Dr. must fill out stating you have tried a supervised diet, but it doens't list any timeframe.

http://www.wellmark.com/Provider/CommunicationAndResources/PDFs/P5341_PhysCertMorbidObesity_IA.pdf

I haven't really decided on a surgeon yet either. I don't think anyone in the Des Moines area has done more than 12 last time I heard. I am thinking I would be much more comfortable with a surgeon who has a few hundred.

I know quite a few people have gotten other BC/BS companies to approve if they need to take NSAIDS, so if they are still not approving it by the time I have my 6 month diet done, I will try and appeal and get it approved on that basis.

Send me a PM if you hear anything!

I am pre-approved for sleeve with UHC I am going with Dr. C @ Mercy WLC. I know he hasn't done that many but I am confident in his skills as a surgeon. He did my mom's RNY 5 years ago and she has had no issues. PM me if you want more details and I can keep you updated on my surgery.

I am being denied by both Anthem B/C B/S and Federal B/C B/S

Anthem is saying it is investigational and federal is saying they will only do it

as a stage procedure with people with high BMI's

I am trying to figure out what to do next.

I am being denied by both Anthem B/C B/S and Federal B/C B/S

Anthem is saying it is investigational and federal is saying they will only do it

as a stage procedure with people with high BMI's

I am trying to figure out what to do next.

What is your BMI? I was approved by Federal BCBS with a 45 BMI. I also did not have any co-morbidities (other than heart disease, diabetes, high blood pressure all run in my family).

Hey!...thats not fair!

lol

Do you know who the nurse was for your pre-cert?

I talked to Darla there yesterday.

I am currently at a 44 bmi, but if I gain 5 lbs I will be at a 45 bmi!

This sucks, huh?

Did you have to do an appeal or anything?

How long did your pre-cert take to go thru?

Thanks,

Lisa

Hey!...thats not fair!

lol

Do you know who the nurse was for your pre-cert?

I talked to Darla there yesterday.

I am currently at a 44 bmi, but if I gain 5 lbs I will be at a 45 bmi!

This sucks, huh?

Did you have to do an appeal or anything?

How long did your pre-cert take to go thru?

Thanks,

Lisa

Hmm, I'm not sure what you mean by pre-cert. I had no appeal, and I'm pretty sure once I applied it only took a couple weeks. I never saw anyone in person from BCBS, if that's what you mean. The bariatric center I go to is one of the "blue distinguished" preferred centers (Genesis Bariatric in Davenport). Before applying I had: orientation, letter from my PCP, a couple EKGs, a stress test & echocardiogram (both extra because of some obesity-nonrelated issues with my heart), psych evaluation (at the center), dietitian meeting, surgeon meeting. Let me know if you have more questions. I'd love to fill you in on what my experience with insurance was, just not sure if I'm answering the right question! :scared0:

Federal BCBS covers VSG as of 2009. But since each state has a different administrator some can be behind the current policy. If it helps, I included a bunch of info on the 22 approvals I found for Fed BCBS and other research on a blog.

My Revision Appeal: From Lap Band to VSG

Britt

Thank you SO much!

You just made a fat lady very happy! :thumbup:

I pm'd you for that additional info, so my doc sent the request up,

if it gets denied, I will have AMMUNITION!

This will be a life saver for me..

Lisa

Sometimes I feel like I'm going into this with a blindfold on. I'm driving myself crazy wondering if I'm wasting alot of time and effort in trying to even have this surgery.

When I went to the seminar I talked with the ins gal and she said she is having no problem getting BC/BS to pay for VSG's. The surgeon told me that BC/BS is not approving the VSG's.

I've checked with my ins. administor's reps and they're telling me that VSG is included in their WLS list (they called a "Sleeve Gastrectomy"), there were no exclusions. The hospital and doc are both in-network.

Am I missing something when I read that almost no one is being approved by BC/BS??

I just read "The Diary of a Fat Woman" blog. It's all about how she fought N Carolina BC/BS until they approved her. I'm getting exhaused and depressed from worrying!!

I think that the one think I have noticed that BC/BS is really different in each state. I believe that they are rolling out apporval to certain states as trials. I think that the other thing that is an issue for BC/BS is not as many US surgeons have exp doing VSGs.

OK and trust the ins lady at the surgeons office. The surgeons really don't have much to do with the ins approval process....

Edited May 30, 201016 yr by BeenThereWasThat

Fortunately I've got great ins. No yearly deductables etc. If I'm in an in-network facility with in-network doc, my surgery will cost me nothing. I say all that to ask, now....if they submit a pre-cert for me to have the sleeve and I get denied, do I have to pay for the consult and all the tests that were done?

My doc requires a 3 month diet to lose at least 5% of body weight before he will operate. So if the ins won't approve me will I be doing all this for nothing?

So sad to say that gastric bypass may be in my future....:svengo:....I know for sure BC/BS WILL pay for that. I do have a few coworkers that have had it and are doing good, as long as they eat right....but I don't want it :lol0:

I believe there are over 39 different BC/BS companies, and they each have their own WLS policies.

You also have policies that differ between employer's. The insurance company may cover a procedure, but your employer may "opt out" of WLS coverage.

I've talked to Iowa Wellmark 3 times and received different responses depending on who I talked to. Their current official policy is that VSG is investigational and not covered, but your particular brand of BC/BS could be entirely different.

Appeals are another topic. These can differ from state to state. Lots of it depends on if your company has an indemnity type policy where the insurance company pays, or a self funded plan where the employer pays, and the insurance company just manages the policy. I've heard the state of california insurance appeal board almost always finds in favor VSG appeals where some other states almost never finds in your favor.

I had to talk to one of the insurance reps who specialized in bariatric surgery as the general insurance reps thought it was covered when it wasn't.

I think within the next year though that a majority of the BC/BS companies will start covering the procedure just because it's a much much cheaper option in the long run than any other procedure.

I just received a return call from Wellmark on Friday...the gal was really nice, but no real helpful information.

I know the current policy was revised in Sept 2009. The gal told me that they typically do revisions on policies every couple of years OR if they receive literature or information from surgeons, etc that would warrant changing it sooner.

I say barrage them with reliable studies that support VSG and see if that persuades them to update their policy sooner than later!!!!

I did some searches of some other BC/BS and it looks like bad news for Regence of Oregon, Utah and Idaho.

Bariatric Surgery

They updated their policy as of 5/1/2010 and still consider VSG investigational.

Arkansas updated in march and still considers it investigational.

Coverage Policy Manual - Arkansas Blue Cross and Blue Shield

[You also have policies that differ between employer's. The insurance company may cover a procedure, but your employer may "opt out" of WLS coverage.]

WLS is included in my policy. I even asked about Vertical Sleeve Gastrectomy. They read and reread the different procedures that were included and they told me they have listed "Sleeve Gastrectomy" as one of the options. I even gave them the code provided by my surgeon's office for VSG and they confirmed that the surgery corresponding to that code is included.

How would I go about checking into Anthem BC/BS (Blue Acess) in Ohio, to see if they are paying for VSG surgeries? :thumbup: