I'm trying to appeal to BCBS of Oklahoma for the lap band & am interested in BCBS's coverage of it in other states...anybody out there know???

I have BCBS of Texas and they have just approved lap band through the federal health plan on the PPO side. One catch is that they have to be over the 40 BMI in order to have it done or under 40 but have one or more co-morbidities. I am only at 37 BMI (but 100 lbs overweight) and don't have any co-morbidities to speak of..... Any suggestions?

100 lbs overweight. You must be experiencing, shortness of breath, backpain, joint pain, difficulty sleeping, depression ( maybe not but this applies to me and I can definately tie it to my obesesity), my sex life was impacted which effected my husband. That is a lot of extra weight to carry but some people do it without any adverse effects.

I'm in Tennessee and I have bcbs of New Jersey and they cover the surgery 100 percent no deductable on my plan it has took some time to get it approved though. I didn't have to do a 6 month diet and it took about 6 to get approved anyway. I started my quest in august and finaly got an approval in Jan, my surgery date is 1/25. Best of luck to you.

I have BC CA PPO. First, they didn't cover the band (when it was new), then they did. Last I checked they will approved the band ONLY for BMI's between 35 with co-morbidities and 40 without and 49. They don't cover it, right now, for BMI's of 50 or greater.

100 lbs overweight. You must be experiencing, shortness of breath, backpain, joint pain, difficulty sleeping, depression ( maybe not but this applies to me and I can definately tie it to my obesesity), my sex life was impacted which effected my husband. That is a lot of extra weight to carry but some people do it without any adverse effects.

Many of the plans list which comorbidities they will accept and they don't care about the others...your sex life or self-esteem, for example.

But, at 100 pounds overweight, you need a (pain the the ass) sleep study. In fact, some surgeons (or anesthesiologists) require one before surgery. Sleep apnea is a life-threatening condition and most people who have it don't know it. (Some of us even INSIST we don't have it...right before we test out as having SEVERE sleep apnea. Duh, me...)

Many of the plans list which comorbidities they will accept and they don't care about the others...your sex life or self-esteem, for example.

But, at 100 pounds overweight, you need a (pain the the ass) sleep study. In fact, some surgeons (or anesthesiologists) require one before surgery. Sleep apnea is a life-threatening condition and most people who have it don't know it. (Some of us even INSIST we don't have it...right before we test out as having SEVERE sleep apnea. Duh, me...)

I've been doing my own research for BCBS and have saved my finds in a thread I started. (it's just so much information) Here is criteria I found:

DESCRIPTION:

Clinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. For purposes of this medical coverage guideline, clinically severe obesity is defined as a body mass index (BMI) of 35 kg/m2 or greater. See the height and weight tables for Men and Woman, BMI tables (100-195, 200-295, 300-400, and formula for calculating a BMI.

Several surgical (bariatric) procedures are used for the treatment of clinically severe obesity. These procedures can be categorized as follows:

• <LI class=bulletedList-1>Malabsorptive procedures - alteration of the intestinal absorption limiting nutrients available to the body OR
  
• Gastric restrictive procedures - reduction in the capacity of the stomach thereby limiting the amount of food ingested.

Gastric surgical procedures for the treatment of clinically severe obesity include:

• <LI class=bulletedList-1>gastric bypass where approximately 90% of the stomach is bypassed and reattached to the proximal jejunum OR
  
• gastric stapling, vertically banded gastric partition, or vertically banded gastroplasty where a proximal pouch of 30-60 ml and a one centimeter outlet are created by a row of vertical staples and a horizontally placed reinforcing band

Certain surgical procedures performed for the treatment of clinically severe obesity may be considered medically necessary when ALL of the following conditions are met:

The member:

• meets the above definition of clinically severe obesity,has been severely obese for at least five (5) years, has attempted a physician supervised (by the primary care physician) non-surgical management weight loss program (e.g., diet, exercise, drugs) for six (6) consecutive months ,has received psychological or psychiatric evaluation with counseling as needed, prior to surgical intervention;
  
• does not have a medically treatable cause for the obesity, (e.g., thyroid or other endocrine disorder).

The following procedures may be considered medically necessary when the above criteria has been met:

http://mcgs.bcbsfl.com/index.cfm?fuseaction=main.main&doc=Surgery%20for%20Clinically%20Severe%20Obesity

Hey John -

Been there, done that, won the insurance battle.

e-mail me and I will forward the letters I used to fight.

Hugs and good luck~!!

hi renebean~

i am also BCBS waiting for my first response from my insurance co...i did see somewhere that you had to have a BMI between 40-49, but when i called the insurance company-they couldn't find that documentation anywhere...so basically i'm holding my breath-i have a BMI of 50.4 or so (depending where i ate lunch at) lol...so i'll keep you in mind if i get a denial!

thanks for the info!

courtney

Mine isnt BCBS...it's BC CA PPO, but I wanted to point out that it changes fairly quickly. Here's from my BC site:

Medical Policy

Subject: Surgery for Clinically Severe Obesity

Policy #: SURG.00024 Current Effective Date: 11/13/2006

Status: Reviewed Last Review Date: 09/14/2006

Description/Scope

Clinically 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 policy addresses those procedures.

Policy Statement

Medically Necessary:

Gastric bypass with a Roux Y procedure up to 150 cm, laparoscopic adjustable gastric banding (the Lap-Band® System), vertical banded gastroplasty, or biliopancreatic bypass with duodenal switch as a single surgery, is considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet the following criteria:

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

*Note: Individuals considering the laparoscopic adjustable gastric banding (Lap-Band®) procedure must meet the above minimum BMI requirement and, in addition, have a maximum BMI of less than 50.

Noticed they actually identified the Lap-Band by brand. Interesting.

It's the only one approved by the FDA at this time. That is why they are so specific. There are other bands but they are still in FDA trials. ~Mandy

How long do you have to be on the insurnce before they will cover the surgery?

minipearl: Depends on your employers contract.......every policy is different.

This is my first post here:

I have a policy with BCBS. It was an HMO plan w/ Anthem in CT, that was recently switched to a PPO plan so that I have coverage in the state I now live in, NY. I haven't even found a regular doctor here in NY yet actually.

They told me that they won't cover the band because my employer doesn't cover it.

Just to be clear - should I submit paperwork to them anyway and then try to appeal after I'm denied? Have people won on an appeal in a case like this? Or do they (people that have won after appeal) mean they were turned down and then won the appeal because their plan actually covered the procedure and as an individual, the request was turned down?

Does that make sense? hehe

To appeal, does that require an attorney?

I'm very upset to find, after all my research, that my insurance plan does not cover the band. I was really scared by my doctor recently when told I am headed for type II diabetes and they want to put me on medication. The insurance will cover that but not the band?! So stupid!! I guess it's the same as covering you to have a baby but not for birth control.

Thanks guys.

This is my first post here:

I have a policy with BCBS. It was an HMO plan w/ Anthem in CT, that was recently switched to a PPO plan so that I have coverage in the state I now live in, NY. I haven't even found a regular doctor here in NY yet actually.

They told me that they won't cover the band because my employer doesn't cover it.

Just to be clear - should I submit paperwork to them anyway and then try to appeal after I'm denied? Have people won on an appeal in a case like this? Or do they (people that have won after appeal) mean they were turned down and then won the appeal because their plan actually covered the procedure and as an individual, the request was turned down?

Does that make sense? hehe

To appeal, does that require an attorney?

I'm very upset to find, after all my research, that my insurance plan does not cover the band. I was really scared by my doctor recently when told I am headed for type II diabetes and they want to put me on medication. The insurance will cover that but not the band?! So stupid!! I guess it's the same as covering you to have a baby but not for birth control.

Thanks guys.

Hey Candle - if your EMPLOYER has an exclusion it is the EMPLOYER you have to appeal, to. The insurance company can only cover what their contract with the employer says they can cover.

Sorry, I am sure that isn't news you want to hear - but check with your HR dept to be sure that your company REALLY has that exclusion. When I was doing my insurance thing - I got a different answer from everybody I talked to when I asked that question. Your HR dept will be able to tell you FOR SURE whether the company has an exclusion. I wouldn't trust the answer from BCBS without a double check. Go to HR first, then confirm with Blue Cross. If HR and Blue Cross conflict in their answers - then get them talking on your behalf.

Good luck!

Thank you ReneBean -

I am going to check with my boss tomorrow - we don't really have an "HR" Dept. I work for a very small company (8 people) I was hoping to not have to disclose any of this to anyone at my job but I guess that's being un-realistic.

So, the owner of my company is the one to decide if insurance will cover the proceedure? Wouldn't they have to change everyone's insurance policy in order to have it covered for just ME? I know the owner of my company would do what ever he can to help me but I doubt they are going to want to pay increased rates for all 8 of us.

This is soooo frustrating!!

Hey Candle - if your EMPLOYER has an exclusion it is the EMPLOYER you have to appeal, to. The insurance company can only cover what their contract with the employer says they can cover.

Sorry, I am sure that isn't news you want to hear - but check with your HR dept to be sure that your company REALLY has that exclusion. When I was doing my insurance thing - I got a different answer from everybody I talked to when I asked that question. Your HR dept will be able to tell you FOR SURE whether the company has an exclusion. I wouldn't trust the answer from BCBS without a double check. Go to HR first, then confirm with Blue Cross. If HR and Blue Cross conflict in their answers - then get them talking on your behalf.

Good luck!

Thanks for this post.

I just finished with my second Appeal, next is state level. I will go through that unless I find success with my employer.

I read my contract and there is an exclusion to gastric surgery. It's very clear. But my doctor does support me in doing so and has written letters and provided clinical information. My insurance company told me that my employer could purchase the rider that included the surgery. I thought he was just trying to sell more insurance. So I called employee benefits and sure enough, the supervisor said "we get requests like this all the time for things like infertility...". I'm now going full on with my employer. I pay for insurance to cover me medically.

I will let you know what I find out tomorrow.

Best of luck.