Devastated by Blue Cross and Blue Shield

[NicoleW8ing 0]

Hey all--

I am a LONG time reader, first time poster. This community answered many questions I was afraid to ask my doctor regarding my lap band, and I want to thank you all right now for just being so helpful and communicative.

I am 23. Right now, I am 5'8" and around 350 *gasp*

I finished my Pre-Op work up through Dr. Moran in Raleigh, NC, for those of you that are familiar. Saw the cardiologist, the nutritionist, the psychiatrist, got the blood gas, the chest xray, the blood work. I am good to go!

They set my surgery date for March 19. Now, my Doctor is telling me that Blue Cross Blue Shield will deny me for lap band as my BMI is greater than 50 and only approve me for gastric bypass. I am horrified beyond comprehension of gastric bypass and am literally panicking here thinking about the remote possibility of it. I was very comfortable with lap band.

Has anyone had a similar situation with Blue Cross Blue Shield? Other insurance providers? Has anyone had success or failure with an appeals process with insurance for these reasons? Has anyone been so scared of gastric bypass they'd rather eat celery sticks for the rest of their life than move on to a normal, satisfying but controlled life with lap band? Gah.... any help, experience, or advice is appreciated.

Thanks people, and have a great day.

:tongue2:

[snowbird 2]

Your doctor said this, but has BCBS? I might also seek a second opinion from another doctor.

[NicoleW8ing 0]

Well, my coordinator at the Doctor's office said it, the one who does my pre-surgery work up. Here's the link to BCBSNC's documentation on morbid obesity.

https://www.bcbsnc.com/services/medical-policy/pdf/surgery_for_morbid_obesity.pdf

Notice page 5, number 3, where they "frown" on banding for people with a BMI > 50.

I am more than frustrated with the insurance company demanding which surgery is appropriate for me, especially considering that LAP BAND is LESS EXPENSIVE than gastric bypass. Also, I have seen data showing that while gastric bypass does have a great UP FRONT weight loss, lap band equals out to the amount of weight loss over an 18 month period.

[Angelica 1]

Hey, your health is up to you, you have the right to address your own health issues the way you see fit. Stand up and make the insurance company listen to you. Tell them that the Bypass isnt acceptable for you. They will listen, you've just got to say the right words.

[KaitlynsMommy48 0]

I just had surgery on 2/13/08 and had one heck of time getting BCBS to even approve me for ANY time of bariatric surgery. They are very particular about the background and having every T crossed. They denied my surgery 3 times before finally approving it so don't get discouraged but don't back down. If you have the coverage and meet the criteria you should be able to use it. Thats my thought process. My BMI was 50.6, I know that is right on the line but they never made a comment about only approving gastric bypass.

Good Luck and let us know how you make out!!

Alison

Banded 2-13-08

Between the liquid pre-op diet and now the post-op diet I've lost 21 pounds!!!

[girlie2shooz 0]

call the insurance company with your approval letter in hand and ask the question. Remember who is telling you this and what their motives may be, but you are ultimately responsible so don't leave yourself at risk. You need to know and have your piece of mind, so make that call with your approval letter in hand and ask BCBS if they intend to honor that approval for exactly what they have approved. go gettem girl. g2s

[Kat817 19]

I know it is very difficult to lose weight---it can be done though without the band---and now may be the time to seriously lose enough to drop you below that 50 mark--should be what 25 pounds?

Work towards that--and ask to be remeasured by your Dr. stretch it out, try to pull off a 5'9" height! It lowers the BMI on the chart--besides who cares how tall it says you are???

Hitting the Atkins induction phase always dropped weight on me quickly----now....it did not stay off. BUT I could lose it. Which is what you might want to consider at this point.

If you can show being 5'9" and drop 20 pounds it should put you on the cusp....I would have to enter numbers tobe sure....but it seems about right. I think at 5'8" you would drop under the 50 mark at about 325.....many Dr.'s require a proof of weight loss prior to surgery anyway---set your mind to it. I know the kicker for me with diets was I eventually knew even if I lost it, I would regain it. But that isn't your worry with this---the goal is just to get it off to appease BCBS....and show your Dr. you do NOT want bypass, you want banded!

I am going to have to get advice from Angelica because my insurance, also BCBS (of TX), did not listen to me one single iota! They split hairs with me til I give up which was their goal!

Good Luck to you----keep us posted how it works out for you!

Welcome to LBT!!

Kat

[shortgal 5]

Just go to a BMI calculator online and enter your height and then keep changing the weight until you see where your weight has to be to be under the 50 BMI, as Kat suggested, it might be just 20 pounds to lose, which as hard as it is, could be do-able.

You could watch the calorie intake, like weight watchers, or do a week or two of liquid meals and add a small salad at dinner.

And yes, call your ins co. and ask to talk to a nurse case manager and explain you'd prefer to go with the less risky surgery.

[Foofy 0]

KAT and Shortgal are right. To be below 50 BMI at 5'8" you have to lose 23 pounds and at 5'9" you have to lose 13. Either of those are doable if you really try. You'll have to be making lifestyle changes anyway, once you get the band, so you might as well make them now. Losing weight will also make the surgery safer.

See this as a challenge to be healthier and not as a defeat or a conspiracy against you. Good luck!

[aubrie 6]

I don't know about you, but for me the choice of the band was a moral and ethical issue established by myself. I could not see myself mutilating the body that God gave me to lose weight. I could however see utilizing a tool to help me do so, that didn't damage my "holy temple" however untidy it appeared to be at the moment. It was reversable and less risky. I value my gift of life, and knew that the risks were far greater with a bypass. I just can't see how an insurance company could have the audacity to force you to have a procedure that you are not ethically or morally comfortable with. That is just plain wrong, and they are far overstepping their boundries. I too was initially denied, but I stuck to my guns. I cried for three weeks and then I just got MAD. it took me 11 months, but I did it and so glad I did. And I'm still comfortable with my decision, and between me and God? I think we're square there to. Just my opinion, but it's heart felt.

[whimsy 0]

I went through a similar situation. Our insurance is through BCBS (now called Anthem BCBS) and they would not approve my lapband since my BMI was over 50.

HOWEVER - as of November 2007 , this was changed. Because of this, they have since approved my surgery and I will be banded on March 3rd.

I highly suggest contacting BCBS and asking them direct questions regarding your policy. In addition, if they *do* advise you that your BMI is not an issue, make sure your surgeon's coordinator mails the appropriate documents to your insurance company.

A lot of times, they have old information on file. If this is the case, they will advise you that you will not be approved based on inaccurate information. My surgeon's office told us they would be submitting paperwork but instead just looked up the BCBS policy information even after we told them the policy had recently changed. Two weeks later, we got a letter from the surgeon advising us that the surgery would not be approved. We called them and asked if they had submitted the paperwork and they admitted that they had not and had only referenced the insurance information they had on file.

Get informed and give your insurance company a call. We had no idea and no notice that they had changed our policy's BMI restriction - my husband just happened to check the policy and lo' and behold it had been amended.

Good luck to you, hon.

[NicoleW8ing 0]

You guys have really pulled me out my slump, by the way, thank you. I was just distraught this morning.

Here's the situation as of close of business today:

Losing weight is not an option. Not because I can't but because BCBSNC calculates my BMI for the surgery out of the AVERAGE of my last 5 years weight. I am the heaviest I have been, but not by much. My average is at 50.9%. Sooooo close. I wish I could just drop the extra weight and be done with it and get it approved. I'd have no problem doing that if it were an option at this point.

Things aren't so bleak though I guess, just delaying my surgery date of March 19 till ?? when my appeal goes through. Truth be told, I haven't been denied yet, so God could smile on me for a moment. I'll have an update from the insurance of whether it is covered or denied by the end of next week. If it is denied, it is off to appeals I go.

You know.... insurance shouldn't be able to decide what is appropriate for me if a Doctor says otherwise. But that's just this liberal's decision. Lol.

Thanks people. By the way, all you banders are lookin HOOOOOOOOOOT!!!!! Keep it up!

[snowbird 2]

Your doctor should be on your side in your Quest for a healthier life. He is the one who should be standing up to BCBS for you, if he agrees with banding. Although it is changing slowly, a lot of doctors are iffy on the band simply because they are not familiar enough with it. My daughter and I had to educate our doctor, but now he is an enthusiastic supporter of lapband. My doctor's theory is that part of his job is to see that our insurance helps provide us with what is best for our health, and he has gone to bat for me several times against my insurance (which is, by the way, BCBS). Talk to your doctor and see if he is willing to support your decision to be banded with BCBS.

[Maya314 0]

Hey all--

I am a LONG time reader, first time poster. This community answered many questions I was afraid to ask my doctor regarding my lap band, and I want to thank you all right now for just being so helpful and communicative.

I am 23. Right now, I am 5'8" and around 350 *gasp*

I finished my Pre-Op work up through Dr. Moran in Raleigh, NC, for those of you that are familiar. Saw the cardiologist, the nutritionist, the psychiatrist, got the blood gas, the chest xray, the blood work. I am good to go!

They set my surgery date for March 19. Now, my Doctor is telling me that Blue Cross Blue Shield will deny me for lap band as my BMI is greater than 50 and only approve me for gastric bypass. I am horrified beyond comprehension of gastric bypass and am literally panicking here thinking about the remote possibility of it. I was very comfortable with lap band.

Has anyone had a similar situation with Blue Cross Blue Shield? Other insurance providers? Has anyone had success or failure with an appeals process with insurance for these reasons? Has anyone been so scared of gastric bypass they'd rather eat celery sticks for the rest of their life than move on to a normal, satisfying but controlled life with lap band? Gah.... any help, experience, or advice is appreciated.

Thanks people, and have a great day.

:tt2:

I didn't hear anything like that at all, I have bc/bs and my bmi is around 52 and some change.. I thought what they submitted for was a CPT code of 43370 (Don't quote me on the exact number) but it's just for gastric surgery and does not specify what type of surgery, have you already gotten your letter of medical necessity? that may play a part in it as well, I wrote my own letter of medical necessity and I specifically put down that I wanted the lap band but my Dr changed it to say bariatric surgery as to not exclude me from anything using that 43370 code. Good Luck, maybe your Dr was just trying to prepare you for something that "Could" happen.

Keep us posted.

[NicoleW8ing 0]

Hey Guys--

Just a quick update. I called Blue Cross/Blue Shield and they just received my pre-certification claim today. I will know whether I am declined or not for sure by Monday. I'm praying my lil heart out that by some grace I don't get declined at all and won't have to deal with the appeal.

If they approve me, I am on track for a March 19th band date.

*sigh*

Here's hoping!