BCBS of GA Lapband "Investigational/Experimental" - Long post sorry!

I am so frustrated!!! I apologize in advance for the long post, but I'm hoping someone out there can help. I spent 2003 fighting with Cigna to get this surgery, going through 3 denied appeals, to find at the end of the year our insurance changed to BCBS and I had to start over. I have spent 7 months dealing with the surgeon's office bungling of getting the pre-cert ready (it would take pages to go into this), and they finally filed in late May. Now, I have a letter of denial from BCBS of GA for Adjustable Gastric Banding (Lap-Band) Surgery that is almost impossible to figure out. I have a scanned copy if anyone wants to see it. My BCBS insurance does NOT preclude WLS. It doesn't seem BCBS is arguing that I'm not qualified for surgery; BCBS deems Lap-band "experimental/ investigational", yet it is the recommended surgery for people with diabetes and IBS, due to healing, leak, and infection problems. But then again, I CAN'T TELL BY THIS LETTER, and no one at BCBS seems to be able to tell me what it is I need to do. BCBS says the surgeon's office must file the appeal; surgeon's office (Dr. Leena Khaitan, Emory Bariatrics in Atlanta) says I must file it; BCBS says that they will not accept from me. I already called to try to talk to the medical reviewer at BCBS; I was told only the surgeon's office is allowed to do that. The surgeon's office said that since they would not do the appeal, that I would have to do that. FINALLY, today, I got a CSR at BCBS that gave me the number for the Pre-cert department and told me to call... on Monday, because it was after 5 pm by that point. ARGH! Between not being able to figure out what I'm appealing, and not knowing how it will be appealed, I'm about to lose my mind. I'm 45 years old, weigh 266 pounds, height 64", have comorbidities of Type II Diabetes, injecting insulin, IBS, GERD, high blood pressure, high cholesterol, asthma, sleep apnea, osteoarthritis in my hips and knees, and fibromyalgia. My specialist doctors (internal medicine, Endocrinologist, Rheumatologist, and Gastrologist) all tell me that by losing even 60 pounds (and keeping it off) will relieve many of my co-morbidities. I have letters from my PCP and Endocrinologist saying it's medically necessary, and suggesting the lap-band over RNY. WLS is not excluded from my plan; BellSouth (the company I work for) has great benefits. Last year, when Cigna was pulling my chain, BellSouth benefits department told me that I should take it to final denial, then their own review board will review. Unfortunately, we changed insurance on 12/31/03, 15 days after the final denial. SIGH. BellSouth has many, many employees who have had WLS, so I know they have approved in the past (and they reinforced that). Why they won't intercede now, I don't know, but I'm planning on taking THAT up with the Benefits department on Monday, too. I also sent an email to the GA Insurance Commissioner's office today, too. Basically the same email I sent to the lists. GA has the law on the books that upholds Obesity surgery, so hopefully, some help will come from that quarter. I've had every test ever known to be required -- or remotely required -- for WLS. I've had the gallbladder sonogram, thyroid, upper GI, endocrine tests, nutritional eval, psychological eval, EVERYTHING. I've 30 years of diet history, 2 6-month doctor supervised diets. I don't think there is ANY way that they can deny on medical necessity or not having done something. I have been sick for 3 years, and have gained over 40 pounds, due to insulin resistance and illnesses related to my diabetes. Since 1998, I have lost, gained, re-lost and regained - a cycle of over 96 pounds. I am now 24 pounds heavier than when I started trying to get WLS in 1/03! My monthly prescription drug bill (my co-pays, not insurance) is over $250. Between the prescription drugs, Dr's ofc visits and tests that I have to have, this insurance should pay for itself in under 5 years!!! If this was a business decision, it would be a NO BRAINER!!! My life is a constant cycle of diets, shots, pills, tests, and doctor visits. I am so frustrated and I'm sick of dealing with this mess. Anybody have any advice? I have a 3" binder full of proof that it is not investigation / experimental, and will be doing more research over the weekend. My surgeon's office is worthless. I called Dr. Ponce's office in Dalton, and even though they are not my surgeon, spent 15 minutes explaining to me what I needed to do. She mentioned the Hayes Report, but when I went to the www.hayesinc.com site, couldn't find it. Does anybody have this? I swear, if I can get this approved, before I stroke out from the stress, it will be a MIRACLE! Thoughts, advice, prayers, commiseration all appreciated! Sherri

The lap band has received FDA approval in the U.S. and can not be denied as "experimental/investigational." Go to fda.com and you can confirm this yourself. Keep the letter you have so you can argue this fact in your appeal. Get the documentaion on FDA approval and submit it with your appeal. Good luck! Vince

Hi Vince! Thanks for the info; BCBS Corporate has a TEC bulletin in which they refute the FDA, and cite their own peer studies. They can deny, but they have been overturned in the State of GA. I was hoping one of those who had their denial overturned would be on one of these WLS lists! Thanks again, Sherri

I also have BCBS of GA and was told up front that the Lapband would not be covered. I am very surprised that your surgeon's office did not know this. I don't think you will be prevented from having WLS, but you may not get the type of operation that you want. I'm afraid that may be their loophole. Did the employees who previously had WLS undergo the Lapband procedure or was it RNY? That may be the reason you are not getting the support you need. I REALLY hope things work out for you!!! I do believe in miracles! I have dealt with the GA Insurance Commissioner's office on another matter, and they were helpful. Best wishes and ((((hugs)))) to you! Becky

Becky, Not sure when you checked. I checked in November 2003, when deciding which insurance carrier to go with. BCBS of GA HAS approved, but in limited cases. I believe that they will approve based on how BCBS of TX, IL and one other state, is now accepting Lap-Band. Those guidelines state in limited cir****tances (and they list them), the Lap-Band is the preferred method. I have IBS, which was one of the cir****tances listed. Their own CSR told me that the lapband had been approved in GA for certain patients, this as late as this week. Also, one of Dr. Ponce's office staff told me that they had had at least one BCBS of GA fight and get approval. I'm looking on the WLS lists for those people, hoping they that still are out there, reading posts, and can give me some pointers. I don't want this to drag out for the full year, as is what happened to me with Cigna. It's just frustrating to still be fighting this, two insurance companies, two surgeons, 18 months and 24 pounds after starting. Unfortunately, both surgeons I've been with have many more RNY patients than Lap-Band, and both preferred RNY. I was told by my current surgeon that Lap-Band would be Plan A, when it was denied, Plan B would be RNY. I flat refused Plan B. Why anyone would want to have their intestines rerouted when a surgery that is safer, has less complications, whose success rate is the same as RNY at 3 years out, and is fully, easily reversible is beyond me. I should have gone to Dalton or Albany; I would probably have had the band by now.

Hi. I also hve BCBS and they told me they will not approve the lap band but have no problem with the Gastric Bypass. They approved me in one day. Good Luck!!

Every state has different requirements so what one insurance co. does in one state does not mean they will do it in another. And the last time I checked (so it could have changed by now) insurance co's dont have to pay for some procedures if they THINK are experimental. And there are a few co's that still feel that way about all WLS's. Mine, Cigna, told me up front no Lap band because it was experimental. Another thing, if your surgeons office is not helping you with this, I'd think long and hard about why you are with this doc to start with. A good group will help you and tell you what you need have and what you need to get approved. Yes they should file the appeal and if they wont, IMHO, I'd find another doc. This is not something to take lightly and if they wont help you now how will they treat you post-op? Good luck to you. Sidney

I'm sure they would accept me as Gastric Bypass. The problem is I'm totally adverse to it. Hmmm... maybe I should get them to approve me for Gastric Bypass, then have the surgeon try to change it, due to IBS & Diabetes, to Lapband. Wonder if this has ever worked for anyone...

I've had some private emails upset that I seem to be putting down RNY. Sorry if I offended you, but as I stated, it is beyond me (which means my understanding) why anyone would want RNY, and then I explained why I picked the lapband. It was not my intention to "dis" RNY patients. You made your choice for yourself; I'm making it for myself. To answer some private email points: Would you refuse a pacemaker if your heart was having problems beating? It is also a foreign body. Proponents for either surgery have studies to prove their point. There are OVER 10 years of longitudinal studies in Europe, Australia and South America on the AGB. The US can't have those type studies because the band has only OFFICIALLY been allowed since 2001, hence the 3 year studies we have here... and the studies, by the way, do show the same results at 3 years out, because RNY has the ability to regain, while lapband still has the ability to adjust restriction. The only difference in the less than 3 years studies is you have a 10% greater ability of losing weight (50%-80%) to lapband's 60%-80%. No matter how you slice it, the lapband has less serious side effects and a much lower rate of mortality than RNY. I have done 18 months of research on bariatric surgery, and I do research for a living. I'm confident I made the right choice, to the point I'll pay for the lapband myself if I am forced to do so. I'm willing to fight for it. Again, sorry if I offended anyone, but I've tried diplomacy for 18 months -- I'm ready to kick some butt now... I was just intending for it to be the insurance's company's!

Normally, I only lurk on this board. But, today I will post. First, let me start by saying that I don't care which one you choose. For the life of me, I don't understand why anyone would want foreign material inside of them (other than a few staples) because sooner or later, the band will erode. I am sure that your research has led you to the findings in several studies on that matter. Also, BCBS GA will probably only pay for 1 MAYBE 2 WLS during the duration of your coverage. Trust me, I know (like the back of mind) what policies BCBS GA offers Bellsouth as well as the other options. And believe me, there is better coverage out there. Ackerman wants you to think that you have "great benefits" when you really don't. Also, the state of Georgia only has a law on the books that requires insurance companies to offer WLS coverage to member companies. THERE IS NO LAW THAT REQUIRES ANY COMPANY TO PURCHASE THIS COVERAGE FOR THEIR EMPLOYEES. Companies can elect not to provide this coverage. You have to make your decisions for YOU like I have to make my decisions for ME. Whether its LAP BAND, VBG (which Emory still does and IS covered by BCBS GA), Duodenal Switch or RNY I hope that you are prepared to fight. I don't understand why Emory will not handle your appeal. There are many people who have been denied for RNY and VBG and they have handled their appeals. Let me also say that Emory is a total piece of $^%(@&$! Dr. K. is my doctor and she is as sweet/nice as she can be but overall they don't have their act together! If you feel that strongly about LAP BAND, perhaps you should consider financing it yourself. If you need any luck fighting Emory, e-mail me and I will be happy to help. Believe it or not, that will be your hardest fight!