Michigan BCBS for GSV

The reason for me posting this is to see if anyone has had any experience dealing with appoval of the Sleeve with BCBS.

I called BCBS today and they said that the laparoscopic Sleeve Gastrectomy is under manual review and that payment for the surgery is not authorized until after the procedure is complete and the doctor forwards all of the criteria that I have met for it.  Then BCBS will decide based on that if they will pay.  BCBS approved the Roux-en-y and Lap-Band but I am interested in the sleeve because the doctor thinks its safer for me because of my weight and I can later convert it to a Y or switch if needed.

This is the email I got from my doctor's staff.

BCBS does not pre-authorize.  If you meet criteria, we can proceed with 
your surgery.  BCBS reserves the right to audit your chart up to 3 years 
post-op to make certain you met criteria.  You have met BCBS of Michigan 
criteria because your BMI is 50 or greater.   Your chart has been passed on 
to nursing to schedule your pre-op testing.  Under BCBS guidelines, you 
have a choice between one of the following:  lap-band, sleeve gastrectomy, 
or Roux-en-Y gastric bypass. 

After reading this I called BCBS.

They said I would need to meet all of the criteria which I do.

Criteria:
1.  Complete 6 months counseling unless BMI is over 50 then it is waived.  My BMI is over 50 so that is waived.
2.  Be between the ages of 18 and 60
3.  Be clinicaly evaluated by a doctor or surgeon prior to surgery
4.  Have documented that I have been notified of the risks before and after and that I understand them.
5.  Have a psych eval

I think I got everything.  So if I understand BCBS correctly I have to meet all of that and have it documented and then the doctor sends it to BCBS for approval after the procedure is comleted to see if they will authorize payment.

That kind of scares me a little even though the doctor says they have been working with BCBS and there is an agreement to have it approved or something along that line.

Anyway, looking forward to hearing if any of you have had the SLEEVE and if BCBS paid for it.

Thanks

That is pretty standard BCBS language...based on what I have heard from others, your surgery should be covered.

good luck!! The Sleeve is a wonderful tool!

1.  Complete 6 months counseling unless BMI is over 50 then it is waived.  My BMI is over 50 so that is waived.

So am I reaching here with the above statement....so are they aprroving for BMI's under 50????
Probably not...but I will call to make sure though. Hope so though!!!

Thanks

Hey Stimpy...

I had BCBS and last year, i was approved because of my BMI within 4 days...

During surgery, my doc opted for the sleeve, instead of opening me up,  because of my size, and BCBS has paid 100% of it--i didnt have to pay a single penny of that...

Dont get discourged or worried...

They will get it approved!!

That sounds about right for BCBS MI. They don't do pre-authorizations (which is what both my HR rep, BCBS, and the surgeon told me). If you meet the criteria, then they should pay, but they do approval after the procedure.

oOO my goodness so after I just posted this I read your thread. I called BCBS of MI and they told me that they will provide a Approval letter to my doctor once he submits all of the information. And I am not to go ahead with surgery until they get pre-approval. Now I am so confused.

I am excited that you have that little bullet point on the criteria sheet saying that patients with a BMI over 50 can have the 6 month supervised diet waived!~ That makes me so stoked. Regardless I turned in documentation from 2005 where I did 11 months of WW b/c my obgyn required me to. However I didn’t keep any of the WW stuff so my doc wrote a letter with all my visits/weights.

I tell ya what I am confused each and every time I have to deal with insurance.  I trust my doctor when he says that it will be covered but I still get nervous so I decided to call BCBS again.  This is the letter they wrote me. 

The procedure code you gave to us was 43659 with diagnosis code 278.01.  This 
code is described as an unlisted gastric procedure.  This service will reject 
under your coverage and will require a manual review by a medical consultant.  
There is no guarantee of payment.

When I see the no guarantee of payment I get nervous.  I have talked with other patients who have had the sleeve done with the same insurance and they said the doctor does everything to show the insurance that you met the criteria and everything is fine.  Just makes me nervous is all.

Anyone else with Michigan BCBS having any luck?