Ugh!! BCBS says experimental!!!

want2lose · July 12, 2006

I just got off the phone with CareFirst BlueChoice insurance. My DH works for Montgomery County, MD, and apparenty their insurance policy follows the Blue Cross "National" policy and not the "Maryland" policy. Lap-band is covered in the Maryland policy, but the National policy lists it as experimental. They will only cover Gastric Bypass, which I really don't want. I thought I had researched this pretty well, but this totally through me for a loop! Has anyone else dealt with this? Is it possible to get past this via appeal?

Thanks!

UPDATE

I got approved on the first pass! I had my initial consultation on Monday, and got a call Thursday that I was approved. I have a BMI of 40, and had my pysician supervised diet records with my at my consultation. I have scheduled all my pre-op stuff, and am scheduled for 9/18 for surgery. It just seems too easy. I was all geared up for a fight with the insurance company.

Thanks to everyone for their support and encouragement.

Mvpo8961 · July 12, 2006

Read this thread.

http://www.lapbandtalk.com/showthread.php?t=10181&highlight=renebean

Alexandra · July 12, 2006

It's absurd to label a procedure "experimental" that's been in place for five years. My bet is that you can have it reversed on appeal. There is no legitimate justification for calling it experimental at this late date.

DrHekier · July 16, 2006

From our experience with one insurance company that is denying the band they are saying that it is 'experimental' because they believe the gastric bypass is better than the Band. You can consider an appeal and you and/or your surgeon should provide articles comparing the LapBand to the bypass.

Good luck!

want2lose · July 16, 2006

Thanks! I'm trying to pick a surgeon and get the ball rolling. I just don't want to feel like I'm getting my hopes up if there isn't a chance. I've been out of work for almost a year, and self pay is not an option. The more I read, the more I know I definitely want this surgery.

ConnieS · July 27, 2006

The LapBand was approved by the FDA in 2001, and by Medicare in February, 2006, so by definition it is NOT experimental, and has not been for 5 years. Those two facts should be the focus of your appeal.

DrHekier · July 28, 2006

The LapBand was approved by the FDA in 2001, and by Medicare in February, 2006, so by definition it is NOT experimental, and has not been for 5 years. Those two facts should be the focus of your appeal.

As my note from above, it appears that at least one insurance company is saying the Lap Band is experimental because they are using data showing that the GB is superior. So I suppose what they are saying is that the LapBand is experimental in the sense that the GB is more effective. I think there is a sufficient amount of data to support the LapBand over GB.and

want2lose · July 28, 2006

I have my consultation on Monday, 7/31, which will get the ball rolling. I picked an in network surgeon, which hopefully will help insurance go smoothly. I will keep you updated. Thanks for the advise!

want2lose · August 5, 2006

See update on first message.

libra · August 5, 2006

Yay!! want2lose!! Good for you!!!:clap2:

Bettina · August 5, 2006

UPDATE

I got approved on the first pass! I had my initial consultation on Monday, and got a call Thursday that I was approved. I have a BMI of 40, and had my pysician supervised diet records with my at my consultation. I have scheduled all my pre-op stuff, and am scheduled for 9/18 for surgery. It just seems too easy. I was all geared up for a fight with the insurance company.

Thanks to everyone for their support and encouragement.

OMG that is awesome!!!!!!!!!!!! You must be soooo excited:clap2: !