Blue Cross of Calif. shattered my dreams

I have called blue cross three times to ask questions. The first call was to see if I was covered for lap band the procedure.Two times I was told yes and today the third call I was told NO and the cust. sevice man was so cold and would,nt help me. Now I have lost hope. How can they do this to me. I filed a grievence online. I just had to get this out cause I cant stop crying. Sue, Oakley,ca

Don't give up sue, try searching for "position statements" or "coverage issues" or other policy definitions online through BC/BS. Get the WRITTEN policy before you give up.... some people (from personal bias) are not going to be as helpful as others. SOOOO get it in writing

Sue - Go here and RESEARCH! I have Anthem BCBS and I don't know about LapBand, but they are covering RNY. Don't get upset yet. Here's the link. Look specifically for medical policies. HA! I just found it... Go to the link anyway and click on MEDICAL POLICIES AND CLINICAL UM GUIDELINES and then put in SURG.00024. It should come up. Now, what you STILL need to do is verify that your employer has paid for this type of coverage. Just because BCBS allows it doesn't mean that your employer has paid for it. You can find that info in your insurance packet from your employer. If you don't have it, go to your human resources dept. and get a copy. Good luck. Please let me know what you find out. http://www.bluecrossca.com/ Policy #: SURG.00024 Medically Necessary: Gastric bypass with a Roux Y procedure up to 150 cm, laparoscopic adjustable gastric banding (the Lap-Band® System), vertical banded gastroplasty, or biliopancreatic bypass with duodenal switch as a single surgery, is considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet the following criteria: BMI of 40 or greater, or BMI of 35 or greater with co-morbid conditions including, but not limited to, life threatening cardio-pulmonary problems (severe sleep apnea, Pickwickian syndrome and obesity related cardiomyopathy), severe diabetes mellitus, cardiovascular disease or hypertension. AND *Note: Individuals considering the laparoscopic adjustable gastric banding (Lap-Band®) procedure must meet the above minimum BMI requirement and, in addition, have a maximum BMI of less than 50. The patient must have actively participated in non-surgical methods of weight reduction; these efforts must be fully appraised by the physician requesting authorization for surgery. AND The physician requesting authorization for the surgery must confirm the following: The patient's psychiatric profile is such that the patient is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and The patient's post-operative expectations have been addressed; and The patient has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate; and The patient has undergone a preoperative mental health assessment and is felt to be an acceptable candidate; and The patient has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; and The patient's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; and The patient's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed. For revision of a gastric restrictive procedure for clinically severe obesity, there must be documentation of a failure secondary to a surgical complication such as fistula, obstruction or disruption of a suture/staple line, and is subject to the same criteria listed above. Not Medically Necessary: Stretching of a stomach pouch formed by a previous gastric restrictive surgery, due to the patient overeating, does not constitute a surgical complication and the revision of this condition is considered not medically necessary . Investigational/Not Medically Necessary: Gastric bypass, using a Billroth II type of anastomosis (also known as a "mini gastric bypass") is considered investigational/not medically necessary as a treatment of clinically severe obesity. Malabsorptive procedures including, but not limited to, jejunoileal bypass, biliopancreatic bypass without duodenal switch, or very long limb (>150 cm) gastric bypass (other than the biliopancreatic bypass with duodenal switch) are considered investigational/not medically necessary as a treatment of clinically severe obesity. All other procedures not listed above as medically necessary are considered investigational/not medically necessary. Further Consideration: A bariatric surgeon with experience in the pediatric population may request further consideration of a case of an individual under 18 years old with severe morbid obesity and unique cir****tances by contacting a Medical Director. Michelle

Hi Sue, I can understand your situation as I work for a BCBS company. I want you to know that you should not allow one CS rep who needs to be RETRAINED to spoil your day. As a CS manager I am fuming that he would even dare be cold on the phone with you. After all, if it were not for the member's we would have no jobs. On the other hand, I believe that you should call back and ask for a CS manager and ask them to not only go over the benefit for WLS and the Lap Band, but to give it to you in writing. I also want you to know that a lot of the time (if not most) it is your employer who is making WLS a benefit exclusion. Keep your head up and try to call again.