ISO Information regarding Blue Shield of CA Access+ HMOSM 15 20%/Zero Facility ded.

Hi Everyone. I'm new to the boards and have just really started researching WLS and the different types.  I'm curious if anyone else has the same insurance as I do and have had this surgery covered?  I'm trying to get an answer from Blue Shield as to what's covered and what my costs will be and they can't provide me with a straight answer.   I'd really appreciate it if anyone with the same insurance could give me some pointers. Thanks so much. Heidi Oh and if it makes a difference,  I'm in Contra Costa County, California

Hello Heidi,

I have Blue Shield access plus through my husbands employer. We have our primary doctor through a medical group (HMO). In order to find out if you are covered for WLS 1. call your doctor or medical group (they have the final say in eligiblity) 2. Call Blue Shield (or your employer ) and get a summary of your coverage.  You can get online with Blue Shield also at www.blueshieldca.com. I had no problems being covered 100% with blue shield access +. I just had to follow my medical groups protocal (6 mos Dr. Supervised Diet and Nutrition Classes and BMI requirements). If you are part of a medical group/HMO- they will have certain Surgeons they deal with for WLS. The best advice I can give is start asap - if you are on the fence, you can always back out but my bet is that you'll kick yourself for not starting sooner. From my first appointment with my PCP (11/07/2006) to Surgery took 10 days short of 14mos (12/28/2007). This included time get referrals to WLS program, waiting for an opening, Dr. supervised 6 month diet, completion of nutrition classes and bariatric education, Medical group authorization to see WLS surgeon, completion of appts for testing and WLS and finally waiting for surgery date. It's alot of hurry up and wait. Its the waiting that will drive you crazy.  I hope this helps -- If you have any specific questions just ask - I'll do my best to help out anyway I can

I'm not sure if ours are the same but I have Blue Shield HMO. I had a BMI over 40 and was approved in 2 days. I had no co-morbidities. My cost $0. I never even had a co-pay until 6months out and I had to pay $10 to follow up with the surgeon. This was one of the biggest blessings!!

I have Blue Shield HMO through my husband's work, also.  I was very surprised at how easy and smooth everything went.  I went through my doctor's protocol, whi*****luded a sleep study (what a surprise, I do have moderate sleep apnea), a visit with a psychologist, and a visit to a nutritionist.  I had to visit two informational seminars, and go to the HMO-sponsored support group. And I had to lose 20 pounds in two months. I saw him again, he approved, stuff was submitted to the insurance, and one day later I got approval.  I have as co-morbidities the newly-discovered sleep apnea, joint issues, and asthma. I went to my first informational seminar in Dec 2007, saw the surgeon for the first time in Jan 2008, and my surgery is on May 12th.  I'm with Camino Medical Group in Santa Clara County. My answer is to check with your HMO/PCP, and start the process.  The surgeon's office can probably get a clearer answer than you can about your coverage. Good luck - Carol

Hey there.....I don't have your insurance but my recommendation is to call your insurance group and go see your PCP so that at least a referral can be processed. Oh, and if you're denied remember you have to be your own advocate and challenge the insurance to be approved.  Keep coming back to the boards to obtain additional helpful tips.  You never know, others might have gone through your same experience and can provide you with information.

Ok, this is what you should do . Blue shield has a policy. What you will need to know is what the employer covers.  You can call the insurance company the procedure code for bypass is 43644. Band is procedure code 43770.  It maybe a covered benefit with the insurance but it needs to be a specific covered benefit to your plan.  Go on line they have a website on the insurance card as well as calling them. Good Luck Liz

I have the same insurance. Send a letter now to Blue Shield asking for weight loss surgery. Get it documented with then NOW!  Blue Shield did cover it 100% but my PCP was the problem. My doctor required the 6 month weekly weight in diet, nut visit, psych visit, echo, ekg, and blood work.  Had to FIGHT with my PCP every step of the way to get referrals and keep them from stalling. Think it was a HMO thing. They hoped they could stall and I would give up. See my blog. I can send you a copy of the letters I sent to Blue Shield and my doctors.  Put all of your requests in writing and if your PCP gives you any grief write and call Blue Shield frequently. I actually filed a grievance with BS about my group and their constant delays.  Within 3 days of receiving the letter I had a date the next week.  It was sooo worth the fight!  I can email you a copy of my letter. Just email me Monday at [email protected]