Bc/bs Insurance For Gastric Sleeve Surgery?

[GonnaBHotMama 18]

I was reading a few posts and noticed that BC/BS seems to be a toughie insurance company. I have BCBS-Texas and was curious how the experiences went with them.

Thx yall!

[Tif 2.0 141]

I have BCBS Texas also and so far while they have stringent guidelines, my experience with them so far has been positive. However, I still have 1 Dr. visit left.

One thing I learned was to call them and ask them if you HAVE to use a Blue Distinction Center or if you can go to another center. Some people went through their whole checklist only to be denied because they weren't using a Blue Distinction Center. It is something your employer and BCBS both agree to. For me, if I was having an organ transplant, I would have to use a Blue Distinction Center, but not for bariatric surgery.

I have to do a 6 month medically supervised weight loss program, have a 5 year weight history, see a nutritionist and have a psych evaluation, plus the standard medical tests. EKG, Echocardiogram, blood work, sleep test, etc.

My last appt is Jan 5th and then it can all go to insurance for approval.

[GonnaBHotMama 18]

I'll have to call and ask about that! I too have to have the 6 months, a bmi of 40+ or 35 with 2 co morbidities, and the psych eval. That's for the insurance, but the doc office does the NUT and the blood work. I always think that I'm gonna get turned down cause of something, but we will see how it all goes. I have the 6 months on my own, not going to the NUT with the office. I am worried about that part of the submission. Hope your submission goes well! I was told that they would submit for insurance approval after my first consult visit on the 28th. Then we could go from there and do all the tests after approval. Crossing my fingers and toes for us!

[Tif 2.0 141]

My BMI alone should qualify me. I'm scared about not getting approved because I didn't see a Doctor in 2010, so I have no recorded weight history. My surgeon's office told me to just write a letter of why I didn't go to the doctor. I basically said I never got sick in 2010 and I weighed over 300 lbs and didn't want to be lectured about my weight so I didn't go. They can obviously see from my weight history in the previous year that it's not like I just ballooned up in one year.

Good luck. I'll let you know how it goes.

[KeepPullinThatRipCord 0]

I used BC/BS of South Carolina (employer offered insurance) Did not have to do a supervised weight loss, had a 40+ bmi with 3 co-morbities ( High BP, Cholesterol,sleep Apnea) The Doctor's office folk did all the heavy lifting. Attended the Obesity Center's initial seminar in March 2011 and was all done with the surgery on May 24th 2011. Pretty easy.

Down to 230lbs. today from a weight of 325 the day of the surgery. No longer on BP meds (96/65 last check),107 total cholesterol and the mask is gone.

Good luck to you.

[mommy794 119]

I have BCBS TX and I had to do a 6 month supervised diet and visits with nut., then a 10 week online program which is required by my job. My healthinsurance thru my job which is a health care facility will cover the surgery if I do all this plus have BMI of 40 or over 35 with co-morbidities. I am in week 8 of my online class so I am hoping to sch. for jan 30th. Right now there is some confusion with the insurance bc I am approved already but surg. office said my copay is 8k but my insurance online says my plan is 80-20 if I use the facility where I work plus I have a max out of pocket of 2500 if I used the facility where I work. This should be correct but I'm going to call my insurance today and double ck. this and if so I will sch. my surg this Wed. for JAN 30!!!!! yayyyyy Insurance is nice don't get me wrong but boy it can be confusing and ALL the companies mite say BCBS but most still have their own independent rules incorperated in as well.

[Shellyac 22]

You should also check to make sure that they don't require a BMI of 50 for the sleeve. When I was considering the sleeve after my original doctor tried to push me towards bypass instead of the band (I ended up switching doctors and will be having the band with plication next week), I was told that BCBS required the higher BMI and that they only covered the band and bypass for my BMI (43). If your BCBS also has the same requirement I would suggest that you have your doctor's office submit the latest position paper from October 2011 on the sleeve from the ASMBS (www,asmbs,org the paper is located about halfway down the page) along with your paperwork. The 50 BMI requirement is based on a previous position statement and since the update is relatively new, it is likely that BCBS hasn't officially changed their policy yet but I am guessing they will in the next year.

[hadouni 301]

I have BCBS in CA and they approved my surgery in less than a week once they got the paperwork. I have a long history of dieting (some medically supervised but confirmation wasn't needed) but there was no pre-op dieting required for me.

My advice to you though is to call and ask them to e-mail you confirmation about what hospitals/surgeons you can use in your area and then confirm that info through your employer's benefits people if your insurance is through an employer. The confirmation thing they sent me expired in 72 hours so if you go that route, print it out or save it so you have a copy. The phone customer service people (over the phone and by e-mail) told me I couldn't go to my chosen surgeon and after a wasted appointment with one of the surgeons they sent me to I found out the ONLY surgeon near me I could use was the one I wanted to go to in the first place!

[GonnaBHotMama 18]

Great advice, yall! I am about to call my insurance company again now! lol I am gonna keep this thread open to make sure I ask these questions. I didn't think about whether or not the surgeon I was going to would be covered as in or out. While that would make a difference in the price I would have to pay, Im pretty much settled on having him as my surgeon, so crossing my fingers and toes that I get some good info when I call.

Thx again!

[GonnaBHotMama 18]

Ok, just got off the phone with the insurance company. She was really helpful. I have a few additional questions to find out, but didnt have the info with me, so I'll find out tomorrow at my appt. My surgeon IS covered! I am happy about that. The doctors that are doing the labs and all that are covered. I need to find out the facilities that they use to double check if those are covered. I found out the max that I will be charged, which is my deductible plus the max out of pocket. I double checked the sleeve requirements and this is what it said :

• "Sleeve gastrectomy (open or laparoscopic) may be considered medically necessary as a surgical treatment option for patients with morbid obesity who meet the eligibility criteria for surgery, including lack of response to the required conservative measures."
  
• I meet the requirements for the surgery as far as the BMI and the psych visit. Since the non medical proof I have is through different docs and programs, we will see how that goes. I also found out that it depends on how the doctors bill something on how it is exactly covered, so I will ask that as well. Now the only thing left is to get approved and find out what I need to pay upfront and what I get billed for or how all that works. Thanks so much guys! Now I feel better that I kinda get what goes on with the insurance. Helps out a ton!
  
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[GonnaBHotMama 18]

Found out today that my insurance has a special coverage for bariatric surgery. There is the 750 copay and then they cover at 50% with no cap! I am discouraged by this and all sorts of pricing is going through my head currently. Anybody else have to deal with something like this?

[mommy794 119]

Same here mine pays 13k flat over that I'm responsible. I dont understand it all yet. But I know the cash price is 14200 so I'm hoping they don't try to stick ot to me bc I have insurance.ladt week they called and said MY part was gonna be 8k which if they already getting 13k from ins. I hope it's not gonna be that muh more but who knows! Its all so confusing. Who knows!

[GonnaBHotMama 18]

I agree!! Whatever happened to flat rates and all that? lol We gotta worry about the surgeon and the hospital and the anesthesia.....sigh. Not very helpful for those that have to pay upfront. lol

[Shellyac 22]

Found out today that my insurance has a special coverage for bariatric surgery. There is the 750 copay and then they cover at 50% with no cap! I am discouraged by this and all sorts of pricing is going through my head currently. Anybody else have to deal with something like this?

Same here mine pays 13k flat over that I'm responsible. I dont understand it all yet. But I know the cash price is 14200 so I'm hoping they don't try to stick ot to me bc I have insurance.ladt week they called and said MY part was gonna be 8k which if they already getting 13k from ins. I hope it's not gonna be that muh more but who knows! Its all so confusing. Who knows!

You may want to check with your doctor offices to see if they would be willing to take the insurance payment as payment as full, it might not be possible in the 50% case but they may be willing to take the loss of a few thousand dollars. A few of the people on the lap band board mentioned their doctors doing that so it might be useful to check out the insurance and financing board over there for more info

[Tana_Q 20]

I'm sorry you guys are dealing with this frustration. It's so maddening to want this surgery and make the decision and then have to deal with the insurance mess. I also have BCBS and hoping I don't run into any surprises with coverage.

Good luck!