I was just contacted by my surgreons office on Friday, regarding the requirements for Lapband surgery. I was prepared for lots of work ie..psych appt 6 month dr weight loss even a nutrionist and 5 year history of morbid obesity, but she seemed discouraged already. She told me that if you go below the 40 BMI during that 5 year period you are automatically excluded. I was shocked and got onto the bcbsil website and read the medical policies on the srugery. It did not say that you could not drop below 40 BMI. I read it as they just wanted to make sure you had weight issues for years not just a short period of time. She continued to state in 2 1/2 years she had gotten only one approval from this particular insurance co. I was getting discouraged, then later in the conversation she proceeded to tell me that honestly when most people find out about all the guidelines and the 6 mo diet they choose to go the self pay route. I think if it is worth doing you have to put some work into it, and that is what my insurance is for! I pay good money for it and think it is worth a shot to get all my stuff together and submit it. I was really just wondering if there were any experiences with this insurance and what was the outcome. Thanks for any advice you have. Tamara

I am certainly no expert, but I have Anthem BC/BS Ohio. I had to have my weight history, but I didn't have one for each year, but provided 7 years. I don't kow how much of that my surgeon's office sent in. And there were times when my BMI was below 40. I have no co-morbibities. Didn't have to do a 6 mo. diet. But perhaps they counted the times when I was dieting and therefore my BMI was below 40. I did have a few months, but not 6 months where I was under my doc's supervision and using adepax.

My understanding is, if you don't have an exclusion on your policy that BC/BS uses a national center to determine benefits.. I don't think the state matters, but the policy does. I may be wrong. If you haven't done so, look at the thread started by Dustout regarding his approval with Anthem BC/BS. I think there's a link there to BC/BS. When I asked them (Anthem) to send me a copy, what they sent was exactly what's on that web page.

If you self pay, your surgeon charges you more than the amount they agree to accept if they are in-network with your insurance. Is there another facility that's more successful at getting approvals? Your are right, you do pay too much for it. If you have no exclusions, I wouldn't think it would be denied.

I have BCBS of ILlinois, having all kinds of trouble, no matter what I send in, it isn't good enough, I have been sent 4 letters wanting all something different, they say it was not in the paper work my Dr. sent in, and you know it was or the Dr. office would not sent it in. they know more about this than I do, Next step will appeal, and I will let a lawyer do that! I pay a good amount for my insurance, have BMI of 40, co morbid health issues, they aren't worth dying for!!!!!!!, Sorry this subject get me alittle rattled. Best of Luck to both os us, Becky (Believe):think

Becky,

While I was approved in about 6 week, it wasn't all smooth sailing. Some of my paperwork also got "separated." In the end I called and while I remained polite, I was also firm that there had to be a mixup. Finally the customer service rep transferred me to a nurse. She got to the bottom of it and I had an approval the next day. Before that, I couldn't get past the customer service reps who kept transferring me to a voicemail that no one ever responded to.

So when were you banded and how long after you recieved approval? Thor, (Becky)

Becky,

What paperwork did you send in? Did you go to a nutrionist? That was recommended to me even though it is not required. Have they officially denied you yet? Thanks Tamara

Yes, I was denied, so now I have a lawyer, I did everything, nutri eval, psy eval,2 letters from 2 different Drs.who wrote letters of necessity,My bmi is over 40, I have co morbid obesity health issues, but that was not good enough.and on top of all that I am 59 yrs old, Have tried every diet known to man, 6 month supervised by my Dr. and 5, actually 6 years of wts and talking about wt and different ways of getting it off. I had prayed and read everything there was to read about lap band, my Surg.was so certain it would be approved in the first week, he was really up set when they denied me, so he felt a lawyer was the best way to go, Thor, (Becky)

Becky

Sorry you have had to go through all that and still they denied you. It is a terrible stress I am sure. I was wondering if they told you why they have denied you. I even told the rep at bc/bs ok well then if you follow all of their guidelines and it is a covered benefit there should be no issues.....right and she just said you never know. It seems like a scam to me. It does get me down and make me want to give up but I think I should at least try. Maybe they just pick and choose by throwing a dart and whoever it lands on will be approved! Seems like that may be the way it works. Also what state is your surgeon in? Sorry for all the questions! Thanks again Tamara

Becky,

I'll be banded tomorrow. I got my approval, about the 20th of November (give or take, my memory isn't the best... especially on clear liquids). Paperwork was originally sent in around the 8th of October. If you'll read that thread started by Dustout, you'll see the details.

I don't know of course if this made a difference, but I'm going to Cincinnati, to Dr. Curry. I had to pay a $300 program fee. That was to have the insurance paperwork filed. The lady who handles it (Tracy) was just awesome. She makes sure the i's are dotted and the t's crossed. She was sure that it would be approved. Had I needed an appeal, the $300 covered one appeal with an attorney. That's how sure they are that they know what they are doing. Now that being said... if there's an exclusion on your policy, they tell you up front that it will not be covered by your insurance. Also she lets you know if you don't meet the company's requirements. I didn't pay anything until she saw what I sent in and was confident it was adequate. Once she have me the thumbs up, I paid the program fee and it was submitted. All of the snafu's were on Anthem's end. (I.E. separated paperwork, information not being entered into the data base, etc.)

Ellisa,

Good luck tomorrow!! I know you will do super! Let us know how things are going when you feel up to it! Tamara

I won't be able to post tomorrow or probably Wednesday, but will get back with you on Thursday.

I will be watching this thread to see WHEN you get your approval. The waiting is absolutely the worst of the approval process.

Take care,

That is absolutely terrible....I bet you money you win your case and you will get the band with the story you have. I will keep you in my prayers. Sometimes they count on people not following through trying to get approved. Good Luck! You will be successful.

I have BC&BS of IL. and was accepted within 4 weeks. My surgery was Aug. 15. I had a psych. eval., thyroid test, letter from my primary care provider, and 3 years of medical records. Good luck.

JP

I had done so much research,reading and when finally making the big decision to go through with it, made sure I read the BCBS hand book, did everything they ask, went to the surgeon, he felt it was a sure thing, so who ever said you can have everything and it still "depends" was right. I am not a lawyer person, but this is something I need, to see my grandchildren grow up, it isn't like I don't have anything else to do, I also know this is not a complete fix, its something you will work at for the rest of my life, who made the insurance God, who gave them the right to say I did or did not have all the paper work. I even had a insurance rep, that I talked to couple times from the main office agree and even went to the pages they said I didn't have and was good enough to flag them so the insurance would see them, the Dr. that was to go over it sent it back to the rep and said he would not even look at it... That right there tells me something is not right with this set up.My sweet husband who supports me and has even called BCBS because it is insurance, says after the first of the year, when I start on a new co-pay they will approve it, see I had double knee replacment in April of this year, so all co-pay has been paid. Its all about the money,even though our insurance payments are out of sight. there are years you never use them then all of a sudden you are in great need for some assist, thats what they don't like. They are to be there to help keep our mind at ease to help us through the trials of our journey through life, not be there at their convenence!!!!I pray for us all, everynight,without our Faith, We are nothing and can do nothing, Thor,Becky BELIEVE

I do not have direct experience with BC/BS but 3 of my friends do. BC/BS of Il had no problem covering this surgery. GOOD Luck!

Oops, this is a thread I didn't get back to. Banded on 12/18/07. It all went very smoothly. My doc allows pureed the day after surgery for 2 weeks before soft foods for two weeks. I'm not hungry at all, but I'm sure that will change once the swelling goes down and the gas is absorbed. I'll keep checking to see how you ladies fare with insurance.