BCBS Aproval problems- Ayone with any type of BCBS please read

[warrior68 16]

I have excellus BCBS Blue Point 2 insurance here in NY, I have been denied again, stating that the sleeve is exploratory / investigational. I am going to appeal the denial, and was wondering if anyone that has any type of BCBS Insurance that was approved for the sleeve to please post here with which company you have, what state you live in, and when you were approved. My thinking is that if I can provide a list of BCBS entities that have covered the sleeve, Excellus BCBS Blue point 2 could hardly then state that it is experimental or Investigational.

I posted this in a couple different threads hoping to have as many people as possible see it, sorry for the over posts.

[Dansha 16]

Hey Warrior, I have Federal BCBS. I had my surgery in August of this year. I had no trouble what so ever. I had to have psycolgical clearance, dietician eval and a EGD. Once this was completed my surgeon's office send a letter of Medical Necessaity to my insurance company. I was approved within three days In July. I live in Kansas and I work for the Postal Service.

I had HBP. Not any longer thanks to the sleeve.

Good luck in your appeal!!! I will be pulling for you.

Deb

[morethan 4]

Medical Policy

Subject:Surgery for Clinically Severe Obesity Policy #: SURG.00024Current Effective Date: 11/18/2010Status:RevisedLast Review Date: 11/18/2010 Description/ScopeClinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. There are a variety of surgical procedures intended for the treatment of clinically severe obesity. This document addresses those procedures.

Position StatementMedically Necessary:

Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example, the Lap-Band^® System or the REALIZE^™ Adjustable Gastric Band), vertical banded gastroplasty, biliopancreatic bypass with duodenal switch, and sleeve gastrectomy (open or laparoscopic) are considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria:

1. BMI of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition including, but not limited to:
   • diabetes mellitus; or
   • cardiovascular disease; or
   • hypertension; or
   • life threatening cardio-pulmonary problems, (e.g., severe sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy); AND

[*]The individual must have actively participated in non-surgical methods of weight reduction; these efforts must be fully appraised by the physician requesting authorization for surgery; AND[*]The physician requesting authorization for the surgery must confirm the following:

• The individual's psychiatric profile is such that the candidate is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and
• The candidate's post-operative expectations have been addressed; and
• The individual has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate; and
• The individual has undergone a preoperative mental health assessment and is felt to be an acceptable candidate; and
• The individual has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; and
• The candidate's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; and
• The candidate's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed.

<br clear="all">

[kncourreges 0]

I was approved in October 2010 by BCBS of Illinois. I had my surgery on November 19, 2010.

Hope all goes well with your appeal!

Kelli

[NLWC.Christa 4]

The policy posted by morethan is the WellPoint coverage criteria. It is used by Anthem BCBS and HealthLink, among others. HCSC, the parent corporation of BCBS Illinois, Texas, Arkansas and New Mexico approved the sleeve in July 2010. Here is the link to the BCBS Illinois policy.

If you look in the insurance section of this forum, you will find several links to well-written appeal letters.

Good luck to you!

[soon to be skinny 0]

I have Empire BC/BS and got my letter of approval today!!!

I have excellus BCBS Blue Point 2 insurance here in NY, I have been denied again, stating that the sleeve is exploratory / investigational. I am going to appeal the denial, and was wondering if anyone that has any type of BCBS Insurance that was approved for the sleeve to please post here with which company you have, what state you live in, and when you were approved. My thinking is that if I can provide a list of BCBS entities that have covered the sleeve, Excellus BCBS Blue point 2 could hardly then state that it is experimental or Investigational.

I posted this in a couple different threads hoping to have as many people as possible see it, sorry for the over posts.

[warrior68 16]

I'm sorry guys, I forgot to come back and update this post, but I did update the other post. I was approved a few weeks ago, and will be having surgery on march 1st at 8am.

[SkinnyGenes 0]

Hi soon to be skinny,

Did you have to go thru the 6 months of weight loss management for Empire BCBS?

[morethan 4]

I was approved on Friday. I am so happy. I will be seeing my Dr. this week to get a surgery date.

[XTrvgnt 0]

I have BCBS of Maryland and this time I had no problems getting approval for VSG. Granted the State of Maryland passed a law that says if you sell health insurance in the state and you have a BMI of 50 or more (or 45 or more with 1 mitigating problem ... diabetes), they can't deny you. They approved me 2 weeks after I met the minimum guidelines with no problems (letter from primary care doctor, evaluations from dietitian, nutritionist, a psychological review, and 6 months of monitored weight loss ... I went with Weight Watchers).