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???

From BCBS Association (corporate)

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5. The improvement must be attainable outside the investigational settings.

The improvement in health outcomes for laparoscopic gastric bypass can be attained outside the investigational setting, if the training of surgeons and the programmatic elements are similar to programs in the published literature, and if performed at a hospital with sufficient surgical volume. However, there may be considerable variation in capabilities and resources among different bariatric surgery programs. To address this concern, Blue Cross and Blue Shield Association and the American College of Surgeons have developed criteria for credentialing and tracking outcomes from bariatric surgery programs.

Based on the above, laparoscopic gastric bypass meets the TEC criteria, when performed in appropriately selected patients, by surgeons who are adequately trained and experienced in the specific techniques used, and in institutions that support a comprehensive bariatric surgery program, including long-term monitoring and follow-up post-surgery.

http://www.bcbs.com/betterknowledge/tec/vols/20/20_15.html

Source found at above website.

Yeah, but isn't this just for gastric bypass? I couldn't find anything about gastric banding in this document. JB

Not sure what you are looking for Airwayman but I'm sure it's somewhere on the BCBS site. If all else fails, just use GOOGLE.

In the US the band has less time on the market than other options. It will take more effort to have studies that show banding as less cost, as effective, and better in the long run for all. It takes longer to loose as much weight as by-pass, at about the three year mark they are the same. Banding does not have the life-long problem of nutrution that by-pass has. Total reversal with the band is possable if in the future something new is better. As of now from a patient point of view the band is best.

In the US the band has less time on the market than other options. It will take more effort to have studies that show banding as less cost, as effective, and better in the long run for all. It takes longer to loose as much weight as by-pass, at about the three year mark they are the same. Banding does not have the life-long problem of nutrution that by-pass has. Total reversal with the band is possable if in the future something new is better. As of now from a patient point of view the band is best.

This is helpful info. Makes sense. Thanks a bunch.

I agree AGB surgery is newer (in the U.S.) than some of the other types of bariatric surgery. But how long is BCBS and some of the other insurers going to use this excuse....calling it 'investigational.' Fact is, it works. There's tens of thousands of case histories all over the world and a growing number of those are done in the U.S. The risk/benefit to the patient is well documented. The potential savings to the insurance industry should be a no-brainer. Wonder why they're dragging their feet?

The Doctors control the information (AMA) there is more money in other opperations. We the consumer need to drive the market for safe, effective, less cost and the way to do it is to push. A free market works.

I have BCBS in N.Y. and they require evidence of a 6 month medically supervised diet, normal thyroid function tests, a BMI of 40 or > or a BMI of 35 with one or two co-morbidities.

I have BCBS in NY. I had my surgery a month after starting this quest. Your BMI has to be between 40 and 50 to have the surgery in most cases. Mine was 56 and no problem getting approval. There was no wait time. I started on Dec 12, got all my consults done by Jan 16th and had the surgery on the 22nd.

Also you only need a BMI of 35 or above with one co morbidity. I have none.

BCBS has many different policies out there. Each one is different. In NY there are approx 15 different policies and several riders.

WLS is covered by my North Carolina BCBS policy...but not the 'gastric band' as they call it. Lots of talk (talk is cheap) about them slowly changing the policy. Some say it may be possible but only after you burn through a couple of appeals. I have no proof of this. JB

APPROVED TODAY by BCBS South Carolina! Documentation including psych and nutrition evals were faxed Friday morning, and my doc got the approval call today. Waiting on the scheduler from the surgeons office to call with a date, and yes in my company's medical SPD BOTH the bypass and gastric banding are spelled out as approved, and yes it had to be medically necessary.... meaning a BMI over 40, or 35 with 2 comorbitites. I qualify with a BMI over 40, and have NO serious comorbitities... The doc has to submit your BMI (to qualify for medically necessary) and yes BCBS will pay for it, because my docs office called them after my consultation and specifically asked them if they covered it and what was required for determination. YIPPPPPPEEEEEEEE FOR ME!

APPROVED TODAY by BCBS South Carolina! , and yes in my company's medical SPD BOTH the bypass and gastric banding are spelled out as approved, YIPPPPPPEEEEEEEE FOR ME!

I don't understand...you live in Kansas City area but have BCBS in South Carolina?

My company insurance booklet covers 'weight loss surgery for the morbidly obese, provided the insured meets the following criteria' (and you know what that is). However it doesn't specify the type of surgery it covers. The BCBSNC policy for Morbid Obesity is the one that excludes 'gastric banding.' I have left two messages with a BCBS rep over the last two weeks. This person has not even had the courtesy to call and say, NO or HELL NO, or, hopefully, that they are looking into it. This reminds me of getting my driver's license renewed....you have no choice....what are you going to do...go somewhere else? Arrrggghhh. JB

Yes I live in Kansas City, but our corporation has locations in multiple states, and our insurance benefits are administered in South Carolina.. The BLUES (as bcbs people call them) are all different companies and BCBS of KC works with BCBS of SC for benefit coordination. So even our people in Colorado or Montana all have their benefits administered out of Columbia South Carolina.....

After reading all your posts I really think you have a bassackwards company to deal with. and in not so polite terms I think you are screwed, and you are smart to self pay... Good Luck

After reading all your posts I really think you have a bassackwards company to deal with. and in not so polite terms I think you are screwed, and you are smart to self pay... Good Luck

It's not the company, my benefits book says they pay for qualified weight loss surgery...it just doesn't say what type. It's the BCBSNC policy that says gastric banding is 'investigational'.

BCBS in South Carolina is paying for Lap Band surgery and North Carolina is not? That's bull***t!!

I was not talking about your employer I was talking about the particular BCBS COMPANY you are talking too.

APPROVED TODAY by BCBS South Carolina! Documentation including psych and nutrition evals were faxed Friday morning, and my doc got the approval call today. Waiting on the scheduler from the surgeons office to call with a date, and yes in my company's medical SPD BOTH the bypass and gastric banding are spelled out as approved, and yes it had to be medically necessary.... meaning a BMI over 40, or 35 with 2 comorbitites. I qualify with a BMI over 40, and have NO serious comorbitities... The doc has to submit your BMI (to qualify for medically necessary) and yes BCBS will pay for it, because my docs office called them after my consultation and specifically asked them if they covered it and what was required for determination. YIPPPPPPEEEEEEEE FOR ME!

SWIMMING WITH JOY FOR YOU!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Way to goooooooooooooooo! You must be thrilled. I am soo very happy for you. All the best, you inspire me. I look forward to reading about your appt.'s, your procedure, your recovery, your slim new body and seeing PICTURES!

APPROVED TODAY by BCBS South Carolina!

Woo-Hoo!!!!!!!!!! Congrats!!! :rockon:

I'm so happy for you - I've been keeping up on your progress.