Hello everyone! I recently finished up most my clearances for BCBS of DE...I just have one nutrition class left in May.

Immediately following my 5th nutrition class I stopped to speak with the nurse to discuss a possible surgery date. At this time, I was informed that my insurance company still views the sleeve as a two part procedure; therefore, they require a BMI of 50 or higher. My BMI is 38.

I'm not really sure why it took five months for someone to share this information with me, but I am absolutely livid! I have HBP, Type II diabetes and (discovered during one of my clearances) sleep apnea. In addition to these issues, yesterday, the cardiologist (another clearance) informed me that I have a slight heart murmur.

Has anyone else ever run into a situation like mine? Were you able to get approved? What did you do??? I'm so desperate. My PCP isn't concerned. He is sure that I will get approved & he plans to fight for me. I don't know what to do.

Nonetheless, if all else fails, I have a backup plan...

My company's open enrollment begins on May 2nd. I could change to Aetna at this time. My new insurance would be effective on July 1. Aetna requires six additional nutrition classes, but that won't be too difficult. It would just push my time frame back. Does anyone know if there is a waiting period if you switch companies? I'm a teacher & I would like to have my surgery over the summer. I wanted to have it in June. Any assistance would be greatly appreciated.

Addition vent---The only issue, at this point, is the BMI requirement. I have been very proactive in trying to find out what I can do to get around this road block. The surgeon is wonderful, but his office staff is horrible. He is the one who suggested the sleeve in the first place. I went into his office to discuss Lap Band, and I have since realized that this is not an option. He suggested the sleeve b/c I have to take anti-inflammatory medication for my ankle & back (from a bad car accident).

I asked if it was possible to speak with the surgeon or receive a call back. The office manager refused to let me speak with him & insisted that I would not be approved. I'm sorry, but this is not her call. BCBS of DE told me that they base their decisions on a case by case scenerio. (Just an fyi of how rude the office manager is--there are three surgeons in the office & she also tried to convince me that the female surgeon was my surgeon. I have never met her, but I have met both of the males.) She was absolutely horrible. Anyway, I waited two days & still had not received a call from my surgeon so I called back. She never sent him the message...Smh!!! I'm sorry, when you are stressed or sick, you don't need the office staff making matters worse!!! The nerve of her! I will be reporting her next week...

So sorry for overloading you with so much information...I'm so stressed out right now. :'(

Little bits

I also have BC/BS but it through the Teamsters I was told they have lowered the BMI to 35 with even one health problem! I think you will be fine, you surgeron with fight with them if need to be!!! good luck and dont let this stress you out!

Thank you so much! I hope that this includes BCBS of DE. **praying**

Little bits

Have you called your insurance to confirm? I called mine (three times!) to double check all their requirements. Sometimes you need to ask to speak to someone who specializes in bariatric requirements. Ask them to e-mail you the requirements and then take them to the office manager. She can't (or shouldn't) refuse to submit your paperwork. Is she the actual insurance person or just thinks she knows everything?

Best of luck, honey. It sounds like with your other health issues that you should be approved. Keep us posted.

Update---The office manager has not submitted my paperwork! So, I scheduled an appointment to see the surgeon. You may be wondering what took me so long...that stupid office wouldn't give me an appointment!!! Anyway, I am under the gun right now & need some advice.

I can continue to fight with BCBS of DE's alleged requirements, which I believe to be worded inaccurately, or I can switch to Aetna. If I switch, the new policy will not be active until July 1. My surgery would be pushed back, but there aren't any bmi restrictions. Has anyone ever switched insurance companies? How did that work out for you? Also, I called Aetna. They do not have a pre-existing clause, so I should be okay...either way, I have until Wednesday to decide. That's when my open enrollment closes.

Sn: The office manager is pushing Lapband and the bypass. I am not interested in either...or, should I just settle? At this point, I'm just tired...

All advice is welcomed!!!

Thanks in advance!

I got my surgery approved by Aetna 1, 2, 3. It was approved within 3 or 4 days of the paperwork going in. I did the 3 month program with them that was super easy and much of what you have already done will probably count towards it. I'd be happy to answer any questions about Aetna.

If they haven't submitted you for insurance, there's not much benefit with sticking with BCBS for the surgery. Are your other costs (deductible, out-of-pocket, etc.) the same between the two? I'm really not happy with your office manager from what you've said, and if she's pushing the two procedures, do you know how many sleeves your surgeon has done? Is he the only surgeon in the area? If you haven't gone through any insurance hoops, you may want to consider looking around on the surgeon score, as well. I know it's a lot to think about with your open enrollment date ending Wednesday, but we're here to bounce your ideas off of! With the odd wording of BCBS DE, all else being equal Aetna might be the way to go, even if you're delayed on your surgery until July. A little delay for a positive outcome is an acceptable thing.

should I just settle? At this point, I'm just tired...

Hi littlebits,

I don't think anyone should ever settle in life. No way, no how.

You deserve the best, i do understand your frustration, but please don't give in. You know what you want, the sleeve is the best, please don't give in. That means "they" have won. You've gotten so far, continue to be persistent.

Perrish the thought, but if you lose the fight for the sleeve, you'll know you gave it your best try.

But that being said, i have faith and confidence in you - and that goes a long way.

good luck

keep fighting

kathy

If they haven't submitted you for insurance' date=' there's not much benefit with sticking with BCBS for the surgery. Are your other costs (deductible, out-of-pocket, etc.) the same between the two? I'm really not happy with your office manager from what you've said, and if she's pushing the two procedures, do you know how many sleeves your surgeon has done? Is he the only surgeon in the area? If you haven't gone through any insurance hoops, you may want to consider looking around on the surgeon score, as well. I know it's a lot to think about with your open enrollment date ending Wednesday, but we're here to bounce your ideas off of! With the odd wording of BCBS DE, all else being equal Aetna might be the way to go, even if you're delayed on your surgery until July. A little delay for a positive outcome is an acceptable thing. [/quote']

Kat, the deductibles are identical...yay!!! Ironically, this particular surgeon is known for VSG. He brought it to DE. He is the head of the bariatric unit @ the largest medical center in the area. Dr. Peters actually suggested the sleeve b/c I need to take anti-inflammatory meds for my ankle.

The office manager is horrible. I'm not happy with her at all. She did apologize to me on Friday, too little too late. I threatened to leave the practice, and she asked me to give them another chance. This is when she FINALLY gave me an appointment.

She had the audacity to say that she is currently working with the office staff on developing "better customer service" skills. I felt the need to inform her that she was the problem.

Thank you so much for being so helpful. I will make the change this week.

Little Bits

Kathy, thank you so much! I am so disappointed with this whole process, but I won't let them win! I just wanted to be on solid foods before returning back to work.

I'm a teacher. I run the summer school program at my school. I gave up my position & decided to take my first summer off for this surgery. Oh well...

Patience is a virtue...I'll wait it out.

Little Bits

Sn: You all rock! Thanks again!!!

Little Bits

Whoo hoo!!! I got my approval today. I'm in the office right now so, hopefully, I will be able to schedule my appointment. Yay!!!

Little Bits

Congratulations!

Thank you!

Little Bits

Whoo hoo!!! I got my approval today. I'm in the office right now so' date=' hopefully, I will be able to schedule my appointment. Yay!!!

Little Bits[/quote']

Congratulations little bits. I go see my surgeon on June 4 and hopefully they will submit after that due to my sleep study shows I have sleep apnea and I'm now on a freakin CPAP.

So great to hear you're approved!