A Tale of Two Insurances

ShrinkingViolet · November 28, 2004

I began looking into getting a lap-band in June 2003. I originally had CIGNA insurance. I had no serious co-morbidities at the time but had a lengthy history of them in my family, including diabetes, heart disease, high cholesterol--everything.

They denied me and said in part because the lap band wasn't proven to be successful. I didn't appeal. Then we switched insurance companies to Blue Cross/Blue Shield. After several months of trying on my own and losing nothing, plus being put on medication for high blood pressure and being diagnosed with borderline diabetes, I contacted my surgeon and got the ball rolling again.

Fortunately I didn't have to do the psych or nutrition appointments. I saw my surgeon on Nov. 1 and Blue Cross approved the procedure within an hour of getting the request from my doctor's office. It was amazing...and a relief.

So I had my surgery on the 23rd. The only thing that may cost me out of pocket is the anesthesiologist. My surgeon works out of one hospital, and that hospital uses one group of anesthesiologists who do not take my insurance. The anesthesiologists insist my insurance should cover it, but Blue Cross says they'll only pay "usual and customary" and I'll be responsible for the rest. I'm not sure how much that will run, and it's a decision I will appeal since I had no choice in which anesthesiologist to use.

My surgeon's office says Blue Cross/Blue Shield (in NY/NJ) is usually very good about approving this surgery. CIGNA is notoriously bad.

leatha_g · November 28, 2004

Cigna approved my surgery within the first week also. The hoops I went through were significantly less than some I've heard of too. However, I don'tthink we can really blame it all on Cigna as a company because each employer choose what coverage they will or will not pay for. Some have Cigna but choose to not cover WLS at all. Some have Cigna and have chosen to pay for WLS coveraged based on medical necessity. It's really our employers who have set the rules. I'm really glad you were fortunate enough to have one of those who chose to take the risk of allowing this great chance to their employees.

Alexandra · November 29, 2004

Hi Shrinking! We have the same doctors and I'm glad to "meet" you! Have you been to any of their support group meetings yet? Congratulations on your banding!!

BTW, I can assure you that the state of New Jersey has a law that states that services provided in network hospitals all have to be treated as in-network. Rest assured, BCBS will have to pay enough of MIA's bill to satisfy them--you won't have any responsibility for the rest. "Usual and customary" does NOT mean you will have to pay the balance.

Don't worry--you're in great shape with BCBS! And welcome to LBT!!

ShrinkingViolet · November 29, 2004

Hi Leatha! I didn't realize it's the employers who choose what to cover. The CIGNA we have here said WLS was covered, but just not for the Lap Band because they didn't feel it was "proven." My doctor took issue with this (of course), because it was approved by the FDA. And I might have had luck if I had appealed but since I had no co-morbidities at the time, I let it drop.

And who's to say that BC/BS would not have been the same way if I had no co-morbidities? I suppose they might have been.

Hi Alexandra! When our surgeons' office recommended this site, they mentioned that one of their Lap-band patients was a regular and someone who always attended the support group meetings. I only wrote down the last name, but I'll bet it was you!

I had to take a pass on this month's meeting as it came the day after my surgery. I will think about next month's but I think they will be difficult for me because I live over an hour away.

I really like Dr. Bertha, and I think the office is great in explaining things and working with the insurance company. I was in a meeting with the scheduler and she took a phone call from some patient's insurance rep., and she was really arguing with him about covering a service he needed that the doctor felt was necessary. She really went to bat for him. It reassured me a lot.

Thanks for the information on NJ insurance. I will look into that in case I have to appeal. My insurance provider is out of NY, because my husband's company is in NY, so I hope they have to follow NJ laws for NJ patients.

I'm clueless about this whole insurance thing.

Congratulations on your successes so far!

Cat

lauri · November 30, 2004

I have BCBS of Texas and they are NOT working with me. Many of you know my story. My husband and I have been insurance shopping and I can't even get any other health insurance because they want to raise their rates 150% because of my weight and health and BCBS says that this surgery isn't medically necessary for me? I really don't understand. I am, also, worried because "for now" I am on COBRA which only lasts another 14 months and then,I guess, I will be without insurance unless I can find a job that has a group plan before my coverage ends.

Alexandra · November 30, 2004

Cat, if your coverage is through a NY company then the rules of NY state will apply. But they are pretty close to those of NJ so I think you're in good shape. I know of another Bertha patient who had Empire BCBS of NY and she had no problems at all with her coverage.

Lauri, unfortunately states each call their own shots with regard to health insurance regulations. If you want to get authoritative information on your options, contact your state's department of insurance (or health, which may be the department governing health insurance). I wish i could help!