BCBS of MI and VSG approval....

Hello Everyone...

I'm going to try and explain something and hope that I don't just confuse everyone... LOL...

So, I'm going for the sleeve and have BCBS of MI PPO Flexible Blue, my friend also has the same insurance and is doing the sleeve....

She is about a month ahead of me...  she did all the stuff, 6 months of supervised weight loss, all the testing, etc....  when we call BCBSM, and give them the codes of 43843 and 278.01 the customer service people tell us it's covered as long as we follow the guidelines, which we have done...

so my friend is done with all the pre requirements and the surgeon's office submitted everything and she was turned down saying they don't pre authorize that code---what is that all about and then why would the customer service people tell you it is covered?

The surgeon's office told my friend that she could go ahead and have the surgery and then they will submit it and it will probably be covered, but they can't guarantee anything, so she is taking a chance....

So, my question is this---what are your thoughts....  do you think she has a good chance it will get covered, since they tell you it's a covered procedure when you call the customer service people and for some reason they just don't pre authorize that code upfront???  that is what the surgeon's office seems to think....

Another question is do you suggest when I get to that point that I also send in a letter stating why this is the procedure I need, hoping they will see that the sleeve is best for me?  if so do you have any examples I could use?

Sorry this is so long and I hope I don't have everyone confused....  Any thoughts or advice would be greatly appreciated...

Thank you, Candy!

There is someone else that post here some times going thru the same.  Maybe she will see  her on the vsg boards.

Insurance companies have teams of lawyers that review and rewrite every clause of their contracts. You can bet that there is a clause that says that if you don't get prior approval, they don't have to pay and you may get stuck. they always cover their butts and you should too. S simple way to see what her chances are of getting approval is to ask the surgeon if it isn't approved will he do it for free. My money is that the odds are not good enough for him to offer to cover that bet.
Insurance companies do not have to offer every surgery and they have teams of accountants and actuaries who determine which things they will cover and which they won't. It's all about the numbers to them, not what may be best for you. I had it explained to me that if the numbers change so will the coverage. So what was covered yesterday may no longer be covered today. I suggest that you and she get the approval, IN WRITING, first. The problem with what ever customer service people said is that it was just said and the policy is not only in writing but legal lingo as well.
Nick

BCBS does not dp pre-authorizations.  I had my surgeryRNY-they stated it was a covered benefit, as long as I met all the requirements.  I did the whole thing 6 months and all. I had the surgery and it was covered.  That's how BCBS does things.  I know it sounds stupid.  That's just how they are.  As long as you did everything by the book-you should be fine.

Erica

I did not know that. If so I would make sure I had a copy of documentation that it is a covered procedure. I suspect that can be obtained prior to surgery. Nothing beats having everything you can in writing.
Nick

Cindy,   As you have been told, Blue Cross, Blue Shield of Michigan does not preauthorize ANY gastric bypass surgery as long as you meet the critera that is supplied to the surgeon.  You can also call BCBSM and ask them to mail you a copy of the medical critera for gastric bypass surgery.  Make sure you ask them to include anything special for the sleeve procedure.   Your surgeon's office is the expert on if you are meeting the criteria.   They are not going to do surgery on someone who they feel does not meet the medical criteria.  After all, it is easier to get money from an insurance company than it is from a patient.   If for some reason you do not meet the medical criteria, and the doctor feels you absolutley need the surgery, they can request a preauth then.  They will only review cases prior to surgery for individuals who do not meet the medical critera - example - a bmi of 38. 

Believe it or not, insurance companies do not look for ways to not pay something. 

I got a piece of paper from my surgeon showing a $0 balance owed by me before surgery.  I almost switched to BCBS before having surgery.  Now I"m glad I didn't.

As a couple of others have stated BCBS does not preauthorize surgery.  Your surgeons office should know this and have had delt with the company enough to know exactly what the criteria is to ensure it is covered.

When I had surgery (RNY) my surgeons office knew exactly what I needed and exactly what phrases my letter from my PCP needed to include. If you look at my profile, there is an entry dated march of 2006 that includes a copy of the letter my PCP had to write. My surgery was covered 100% (except what I had to pay to meet my deductable).

Good luck to you both!

I can't get to your profile to see the letter, it says it's private...

Candy