OK folks .. I'm trying something and I'll let you how it goes.

I am a benefits/HR person for my company, and it was at the BCBS SC office this past summer that I was at their office for "train the trainer" meetings... it was there that I found out that our SPD ALLOWED for WLS, because I am HR, I am the main contact for my company with BCBS and we were given a special person to be our contact......... anyway... I just sent HER the following email: (btw thanks for posting the billing codes)

Hello Lisa!

Here at the Mother House location, we got our new ID cards in Tuesday’s mail. YEAH!

I have a question for you. In 2007 I’m going to be having a Lap Band put in,

CPT Billing Code: 43770 – Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric band (gastric band and subcutaneous port components).

I’m also enrolled in the CDHP (HRA plan), and utilizing the FSA.

I know that in our SPD we have a provision for it, my question for you is there any special paperwork for OUR PLAN that I will need to complete. I know a couple other employees have approached me already with the same kind of questions, and I want to help THEM as well as myself……….PLEASE HELP.

My surgeon is a Teir 1 provider and the hospital is a Tier 2.

Thanks for all your help!

CROSS YOUR FINGERS FOR ME!!!!!!!!!!!!!!!!! I want to be a bandster EARLY in 2007

Update: I have not yet heard back from bcbs, but I did get a call back from my OBGYN office (this office is the closest thing I have to a PCP) because I've been going to them since 1999... ANYWHOO

I told them what I was going to do, and that they could help me by providing a letter stating my long history of being obese... and the different meds they prescribed me over the years..... SHE was Like SURE!!! We will dictate it and get it in the mail next wednesday! (their office is closing early today and opening back up on wednesday)

I'm hoping to hit the road running with all my pre consult leg work!

Update:

Well I got the following email back today....... generic really

Tracy,

Good Afternoon.

Lisa is out of the office for the remainder for the week. Morbid Obesity Services are covered as long as medically necessary according to BCBS medical policies.

This is a service that will require precert.

If you have additional questions, please advise.

Have a Happy Holiday!

Update: I recieved the following email from BCBS this morning! PRETTY EXCITING! (I had questioned her about OUR COMPANIES SPECIFIC POLICY)

Tracy,Happy Friday.I do apologize. Your plan does not require precert for inpatient services.However, I would recommend that you still call precert and have this reviewedfor medical necessity. Once medical necessity is determined, this informationcan be noted on your account for this service.Please let me know if you have additional questions.Thank You,Tiffany

Good luck with that tracy.. It sounds very promising.. I am in a similar situation.. bcbs MA . does cover WLS. on my first denial because bmi was 37.5 and not medicated for High blood pressure (yet). anyway I plan to submit a new claim after jan 1 because like always after the 6mo plan I have packed on all I lost and then some.. so with the 40 bmi and a new set of blood tests and a letter from my pcp??? so anxious and tired of fat..... myturnow..donnaco

Good luck. I have BCBS in Texas and I was approved so I'm hoping the same is true for you! My lapband has been a gift for which I am truly thankful.

Thanks ladies... I can barely contain myself...... I have to go to a seminar before scheduling a consult with the surgeon... and I'm hoping to just blow them away with all my paperwork.

I upped my Flex Spending Account to make up for my outta pocket max... if this doesn't go through, I'm going to be buying A TON OF OVER THE COUNTER MEDS! LOL

UPDATE: I just got off the phone with the program coordinator at the surgeons office.....

I am scheduled for the seminar on 1/6/2007, and she went ahead and scheduled my consult with the doc on 1/8/2007!!!!!!!

wooooohooooooooo!!!!

Hey Tracey,

This must be very exciting for you. Can't wait to see your results!! I have a few questions for you if you don't mind. FIrst I am new here and have jsut started looking into the Lapband procedure. I have Federal BCBS of Delaware. They have been really great in the past with all of my surgeries for disk problems etc. I am also on BP meds as well as migraine meds. What do you think think the chances of my insurance covering this procedure with a BMI of 35.5?

Thanks

Jeanette

Hey Tracey,

This must be very exciting for you. Can't wait to see your results!! I have a few questions for you if you don't mind. FIrst I am new here and have jsut started looking into the Lapband procedure. I have Federal BCBS of Delaware. They have been really great in the past with all of my surgeries for disk problems etc. I am also on BP meds as well as migraine meds. What do you think think the chances of my insurance covering this procedure with a BMI of 35.5?

Thanks

Jeanette

I would check with your HR/Benefits person, ask her what your SPD says... for instance ours say BMI over 40, OR BMI of 35 and two comorbidities........ also you could call BCBS and ask them what your SPD says... (they should have it loaded to their system for refernence)

Happy New Year!

Since my last update I have recieved the letter from my OB's office stating my history with obsesity and the scripts they had given me, my battle with PCOS and infertility....

Also, since it is the new year I went and created my profiles with BCBS and found out that the amount in my FSA is wrong.. so I've been emailing them waiting for an update......

I have an HRA, and on my card it clearly says NO PRECERTIFICATION is required....... so I'm wondering if I would be borrowing trouble if I called them and made sure they knew it........

ONe week from today I will be meeting with the surgeon... I'm so excited but also anxious.

I don't know if anyone but me is keeping up with my battle..... but here is the latest...

I bit the bullet and called the customer service number on my card and they transfered me to MANAGED TIER, which deals with precertifications.

I just went round and round with a workerbee, and then the supervisor...

they both told me that I would indeed be required to be approved, and have to go through a precert. (My ID card says NO PRECERT Required) and our Open Enrollment Booklets clearly highlight it (on page 16) I read it to her..... I explained to her that we have 3 plans 2 PPO's and 1 CDHP, the CDHP is what I have...... (I also quoted back an email from the Tiffany person)....... this made the supervisor backpeddle and she is now reasearching it..... (She said.. well it's obvious you know your benefits, and I said, yes.. it's MY JOB, for my company.)

I also quoted our SPD requirement of BMI requirments. I told her that I have my consultation with the surgeon one week from today, and I have been working with the program coordinator to make sure everything goes smoothly... she did say that it was investigational.. and I said, it is no longer investigational...as of November 2006, and it under billing code: 43770............. THIS WHEEL IS A SQEAKING BABY!!!!!!!1

I will update when I know the outcome.....

More as of today!!!!

I did get a call back from the supervisor person and she APOLOGIZED about the confusion. She said I was indeed correct, I did NOT need a pre-cert for my CDHP plan.... (YIPPPPPPPEEEEEEE)

but she cautioned me to go ahead and do one anyway just to make sure there isn't any problems with the billing... (I'm thinking in my head. YEAH RIGHT, give me my band and I'l deal with billing issues later!) SQUEAK!SQUEAK!

I just emailed the insurance coordinator for my surgeons office breaking down my insurance plan. I hope to hear back from her with a break down of what is going to be expected out of my pocket....

(It would be a dream come true if I could push all this through and get my band by the end of January)

It's now the wednesday.. my consult is Monday the 8th....

I mentioned in an earlier post that I had upped my FSA to cover my out of pocket max... I did this right before bcbs mailed out the cards, and yesterday they still showed the lower original amount, but I emailed them and today it is fixed.... this means that i'm going to have quite a bit of flex dollars to use... I swear if this flops everyone is getting baskets of OTC meds next year for Christmas. LOL

This is also what I've done:

1. a copy of my "weight loss" chart starting from after the birth of my son in 2003... (It goes up and down ALOT)

2. a timeline of me in pics, starting in 1998.... (I go up and down a lot) this is to prove that YES I've TRIED, Failed, Tried, Failed

3. A copy of the letter from my OBGYN.. which goes back to 2000, listing my struggles with my weight and infertility

4. Copy of my last Thryriod panel...

5. List of all the drugs I take and the dosage

Things on my to do list are to pull my bank statements with my CURVES membership on them, and now that I think of it, I have an OLD Ballys membership too that shows up on my credit report.... I'm trying to DO everything, just in case the docs offices makes me do a precert, or if I have to do battle

TracyinKS you go.. I am enjoying watching a pro at work.. sometimes I have a very hard standing up for myself.. others too.. confrontation not my strong suit... but you have such courage... You mentioned your thyroid pannel ...I am trying to get my thyroid meds (synthroid) in the proper amount .. to re apply for coverage.. i have achieved the 40 bmi.. thanks to the holidays..(not my brightest move I fear the OMG what if they dont come thru???) but we press on... I am going for new blood work tomorrow and my weight also...wish me luck.. and I do the same for you..we will band ....donnaco myturnow

LOL! thanks Donna....

I did get kind of a depressing email back from the insurance coordinator at the surgeons office..... but this tells me that she has never worked with my kind of plan, so I'll have to educate her too..... I'm going to spit nails if I have to do a 6 month diet plan.... but little does she know how I am when I'm fired up about something..... Just over the phone I had 2 supervisors backpeddling... (See I really think this is a loop hole, that wasn't closed up, because my company JUST switched to BCBS, and they REALLY put on the dog and pony show for us to join up) but here is her letter......... (I'm taking my enrolment book with me to show her), and all the names and numbers of people I've talked to and WE will call them after my consult.... so I might just have some kind of answer on Monday afternoon.

Dear Tracy,

Please give me a call on Thursday if possible so we can go over some of these things. I have never heard of a bariatric surgery not needing pre-cert but this could be something different. The reason I say that, is in order to use a bariatric benefit your insurance has review your history to see if this surgery is medically necessary for you. If they didn’t have to review it then people who were 20 pounds over weight could have the surgery and their insurance would pay for it. Does that make since? Insurance is a totally different ball game when it comes to bariatric benefits. What I would have to do is after your appointment I will call your insurance company and talk to them. Until then I couldn’t tell you much. But just to be completely honest with you most likely your insurance has criteria they will want to see prior to approving you for a bariatric surgery and if they want for example a six month diet with monthly notes from your doctor then you would have to complete that before they would approve you for surgery. Unfortunately, letters from your doctors stating your need for surgery will not get you past having to meet these criteria. We have patients that there life is at risk if they don’t loss weight and we have letters from there doctors stating just that, and they will not approve them until they meet the same criteria that all other members have to meet. Again, your policy could be different but I just wanted to tell you that the chances our slim. Please call me on Thursday if you have any other questions.

Sincerely,

Rachel H.