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My VSG approval Process Anthem Blue Cross Medi-Cal



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I decided to write this timeline because I feel that it is important for other people to understand this process and what to expect. In May, 2014, after careful research, I decided that I wanted to have gastric sleeve surgery. I have struggled with weight my entire life. Although I have never had any major health issues or what most insurance companies consider co-morbidities, at the age of 40, my weight was starting to affect me.

I began my research with Anthem Blue Cross, making sure the procedure was covered and to understand their specific criteria. I knew ahead of time what labs and x-rays I needed. My first trip to my PCP was early June. I knew that at a weight of 225 and height of 5’4, my BMI was between 39 and 40 so I put on an extra 10 pounds so that I knew I would be covered. She ordered all my tests. I found a hospital (Bakersfield Memorial) and surgeon (Dr. Snyder) that I liked and scheduled a seminar. When I spoke to the nurse who schedules everything for the surgeon, she informed me that how fast this process takes will be up to me. This is why I had all of my tests done prior to my seminar in July. I was ahead of the game believing that a six month wait time was not going to apply to me.

Labs, xrays, ekg, abdominal ultrasound all looked great so now it was time to get my surgery consult. Of course this requires an authorization from my insurance. It was at that time that PCP staff advised me that they were way understaffed and authorizations can take up to two months. This was ridiculous in my opinion so I became a major pain in their ass. After about a month, I was informed that my authorization was denied by my insurance because it was not a covered service. I called Blue Cross who informed me that they have nothing to do with authorizations. My medical Group (Independence) must have denied it but I could not contact them directly. Blue Cross attempted to contact them for me but had to leave a message. I finally returned to my Drs office only to be told that my paperwork was misplaced so she could not give me a reason for my denial. After much persuasion, she gave me the number to my medical group. I spoke with the assistant director of Utilization Management who then informed me that my Drs office put the authorization in as a behavioral health consult rather than a surgical consult. She corrected it right away and gave me an authorization number.

I called my surgeons office and scheduled my consult for September 10th. The nurse informed me that I should wait until after the consult to schedule my psych eval and nutrition consult. I decided to get the nutrition consult done prior to the surgery consult because it was covered by my insurance. The consult went great and I was told as soon as they received the psych and nutritional paperwork, they would submit it for approval. Once approved, they could get me in right away for the surgery.

I decided to pay extra for my psych eval because he works directly with this surgeon and guaranteed he would send the report the next day. 4 days after my consult, I was done with everything. A week went by, I heard nothing. I called the nurse who informed me she had received the nutritional report but it was cut off in the fax. And she had never received the psych report. I called the psych office who faxed that paperwork right away but still could not get that nutrition report to fax correctly. I decided to make the 40 minute drive to pick up the report myself. After all, the nutrionist assistant was on vacation and she didn’t know how to fax. How do you have a college degree and not know how to fax? So finally, all paperwork was in and the nurse sent it off for approval. Actually, she submitted it to the hospital staff who took another two weeks to send it for approval. Another week went by only to learn from Independence Medical Group that my insurance company denied me because I did not meet the criteria. We wouldn’t know what that meant until I received the denial letter and then I could appeal. I was so angry. I knew that I met the criteria, which was a BMI over 40.

Another week went by and the surgeons nurse called me to say that I needed two co-morbidities. I explained that it was incorrect and I had already contacted Blue Shield to make sure that I had it correct. So instead of making phone calls to get this straightened out, she told me the surgeon was going to order more tests to try to find something wrong with me and we could re-submit everything and try again. This blew my mind. Instead of getting to the root of the problem, let’s spend more money. So, I contacted Independence medical group who stated they denied it based on Blue Cross criteria and if their criteria was incorrect, Blue Cross would have to notify them. I contacted Blue Cross who then contacted Independence Medical Group to get it all straightened out. So now it was back under review until they received the correct guidelines. Two more weeks went by, no change, no denial letter, no review, no nothing.

Needless to say, my level of frustration was very high. I decided to call Independence Medical Group and by some great fortune the assistant director who helped me before answered. I explained the entire situation to her and she approved it again over the phone and educated her staff. A second approval was required through Blue Cross which took a couple more days. But as of Friday, November 14, I am officially approved. The Surgeons nurse called me to congratulate me and inform me that they probably couldn’t get me in till after the holidays but she will call this week to let me know for sure.

The entire process when all is said and done will probably be 7 to 8 months but I did not give up. I will have this surgery. I just want anyone struggling with the approval to understand that not too many people are going to go out of their way to help you. It is up to you to make the calls and bug bug bug. Turns out the assistant director has WLS herself so she was a big advocate. If it had not been for her, I may still be fighting this.

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Congratulations and good luck with your surgery. Nice to be determined. Proves how much you want this.

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Persistence definitely is a must in this process. I'm awaiting insurance approval myself. I pray it all goes well. Good luck to you and Congrats!

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Thanks ladies and good luck to you both!

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That is awesome to hear! I am on round two of insurance approval after being denied 2 years ago. Best of luck with your surgery and wishing you a speedy recovery!

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    • LeighaTR

      Four days post surgery. I am sipping as fast as I can and getting NO WHERE near the goal of 60 - 80 grams of protein or the 64 oz of liquids. I just feel FULL. I don't know if it can still be the gas build up (I would think by now that would be gone) but it is a struggle to drink. And so far I have not had the nausea or spasms and don't want to wander into that territory by pushing too hard with liquids. I about passed out today as it was my most "strenuous" day. Went from second story to basement for shower and I was sure I was going to pass out. Looking back on my last few days I have had a total of less than 1000 calories. Am I just not getting enough nourishment in me? Once again a friday where I can't get ahold of the doc until Monday rolls back around so I am hoping maybe someone here has some experience on how to keep energy going. I do have fibromyalgia too and that may be where some added fatigue comes into play. How did you all fair with the goals the week after surgery?
      · 0 replies
      1. This update has no replies.
    • Doughgurl

      2 days until I fly out to San Diego to have my Bypass Surg. in Tiajuana Mexico. Not gonna lie, the nerves are starting to surface. I don't fear the surgery itself, or the fact that I'm traveling alone, but its the aftermath that I'm stressing about the most, after this 8 week wait. I'm excited to finally be here, but I am really dreading the post surgical chapter. I know its going to be tough, real tough and I think I'm just in my head to much now that the day i here. Wish me luck, Hopefully I'm one of the lucky ones, and everything goes smoothly. Cant wait to give an exciting update,. If there is anyone else have a June bypass or even a recent one, Id love to have someone to compare war stories with. Also, anyone near San Antonio Tx? See ya soon with the future me. 💜
      · 3 replies
      1. Phil Penn

        Good Luck this procedure is well worth it I am down to 249.6 lb please continue with the process..

      2. Selina333

        I'm in Houston so kind of near you and had the sleeve in Dec. Down 61 lbs. Feeling better. Was definitely worth it. I hope the everything is going well for you. Update us when you can!

      3. Doughgurl

        I am back home after my bypass surgery in Tiajuana. I'm post op day 4. Everything went great! I guess I'm one of the lucky ones who have not encountered much pain at all, no nausea thus far and I'm having no problem keeping down broths and water. Thank you for your well wishes. I cant wait to keep up this journey and have a chance at better health and simply better quality of life. I know there will be bumps in the road ahead, and everything won't be peaches and cream, but at least I have a great start so far. 😍

    • LeighaTR

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      · 0 replies
      1. This update has no replies.
    • Doughgurl

      Hey everyone. I'm new here so I thought I should introduce myself. I am 53y/o and am scheduled for Gastric Bypass on June 25th, 2025. I'm located in San Antonio, Texas. I will be having my surgery in Tiajuana Mexico. I've wanted this for years, but I always had insurance where bariatric procedures were excluded. Finally I am able to afford to pay out of pocket.  I can't wait to get started, and I hope I'm prepared for the initial period of "hell". I know what I have signed up for, but I'm sure the good to come will out way the temporary period of discomfort and feelings of regret. I'd love to find people to talk to who have been through the same procedure or experience before. So I look forward to meeting you all. Hope you have a great week!
      · 2 replies
      1. Selina333

        I'm so happy for you! You are about to change your life. I was so glad to get the sleeve done in Dec. I didn't have feelings of regret overall. And I'm down almost 60 lbs. I do feel a little sad at restaurants. I can barely eat half a kid's meal. I get adults meals often because kid ones don't have the same offerings at times. Then I feel obligated to eat on that until it's gone and that can be days. So the restaurant thing isn't great for me. All the rest is fine by me! I love feeling full with very little. I do wish I could drink when eating. And will sip at the end. Just a strong habit to stop. But I'm working on it! You will do fine! Just keep focused on your desire to be different. Not better or worse. But different. I am happy both ways but my low back doesn't like me that heavy. So I listened (also my feet!). LOL! Update us on your journey! I'm not far from you. I'm in Houston. Good luck and I hope it all goes smoothly! Would love to see pics of the town you go to for this. I've never been there. Neat you will be traveling for this! Enjoy the journey. Take it one day at a time. Sometimes a few hours at a time. Follow all recommendations as best you can. 💗

      2. Doughgurl

        Thank you so much for your well wishes. I am hoping that everything goes easy for me as well. We don't eat out much as it is, so it wont be too bad in that department. Thankfully. Also, I hear you regarding your back and feet!! I'd like to add knees to the list. Killing me as we speak! I'm only 5' so the weight has to go. Too short to carry all this weight. Menopause really did a doosey on me. (😶lol) My daughter also lives in Houston. with her Husband and my 5 grand-littles. I grew up in Beaumont, so I know Houston well, I will be sure to keep in touch and update you on my journey. I may need some advice in the future, or just motivation. Thank You so much for reaching out, I was hoping to connect with someone in the community. I really appreciate it. 💜

    • Alisa_S

      On day 4 of the 2 week liquid pre-op diet. Surgery scheduled for June 11th.
      Soooo I am coming to a realization
      of something and I'm not sure what to do about it. For years the only thing I've enjoyed is eating. We rarely do anything or go anywhere and if we do it always includes food. Family comes over? Big family dinner! Go camping? Food! Take a short ride or trip? Food! Holiday? Food! Go out of town for a Dr appointment? Food! When we go to a new town we don't look for any attractions, we look for restaurants we haven't been to. Heck, I look forward to getting off work because that means it's almost supper time. Now that I'm drinking these pre-op shakes for breakfast, lunch, and supper I have nothing to look forward to.  And once I have surgery on June 11th it'll be more of the same shakes. Even after pureed stage, soft food stage, and finally regular food stage, it's going to be a drastic change for the rest of my life. I'm giving up the one thing that really brings me joy. Eating. How do you cope with that? What do you do to fill that void? Wow. Now I'm sad.
      · 1 reply
      1. LeighaTR

        I hope your surgery on Wednesday goes well. You will be able to do all sorts of new things as you find your new normal after surgery. I don't know this from experience yet, but I am seeing a lot of positive things from people who have had it done. Best of luck!

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