newbie...totally lost

I don't know if this is where I should be or not.  If not, I'm sorry. 

First, I'd like to introduce myself.  I'm Melissa, live in SW Michigan and am looking at getting VSG.  I have a wonderful hubby and 3 kids -- 2 little boys and a sweet step daughter.

Now to my questions.  I don't know where to start my journey towards a thinner and most importantly, healthier me.  I did call my insurance company (BCBS PPO) today and found out that they do cover WLS, but only RnY, from what I understand.  Is that the be all end all answer or can I/my dr appeal to get coverage for the VSG?  They do cover it, but only as a 2nd to DS, I guess?  Do I go back to my PCP now and tell her that I'm interested in WLS when I've never mentioned it to her before? 

I'm sure I'll have a thousand more questions. I just don't know where to go from here.

Thanks in advance for the replies!
Melissa

Melissa,

Hi, welcome.

I don't know if you can appeal a benefit option or not, I really doubt it, but you can always try.  I have BC of NY, but from what I've read, BC of MI does not "pre approve" wls.  They ask for records post op, review them and make a determination at that time.  Your surgeon will know who does and does not qualify for wls, trust me they do not want to do surgery on someone they know will be denied.

As for your family Dr., most insurance companies require you to do a physician supervised diet for 6 months.  So my guess is she'll know :).

Good luck,

Edie

Hi Melissa,

Many insurance companies don't cover the VSG.  They may in the future, as the results are proving to be similar to the RnY.  If your insurance covers RnY, it likely covers the DS (see my profile for links to information on the DS).

My advice to those seeking information on WLS is different than a lot of others I have seen post.  I am pretty strong about advocating for my health, and tend not to take a passive role and let others (like my PCP or insurance company) determine what is right for me, so with that in mind, I would:

1)  Study all of your WLS options, and determine with WLS is the right one for you.  I would not rely on a PCP to determine this, as they are really not as familiar with WLS as they sometimes project.  Also, if you are consulting a bariatric surgeon, you will only hear about the WLS options they are capable of providing, not necessarily all of your options (or the truth about the different options).

2)  Once you know what you want, consult with a surgeon that performs ALL the options (there are only 4 surgeons in MI that do all four major surgery options), so you are sure you are getting accurate information, not biased by their level of surgical skill

The bariatric practice will have a program that will start your process, and get you on the road to insurance approval, pre-op testing, etc...

Certainly, having your PCP on board is not a bad thing, but you don't have to start there.

Hi Melissa,
Welcome to your WL journey. Stay on the OH list and you'll get lots of help and advice.
I am friends with the Medical Assistant that works for my Bariatric surgeon.  She says BCBS no longer has the 6 month diet rule that a lot had to go through prior to surgery.
First, do your research.  Most hospitals that do Bariatric procedures have an intro program held once or twice a month that introduces prospective patients to weight loss options, surgery types and what you need to do to move forward.  They can advise you on what you need to do to go to your PCP.
VSG is still considered "experimental" by some insurance companies and some require a higher BMI, 50+, before they will allow it.  RNY has been so successful by so many as are the band procedures.
Please keep posting and we'll be there for you!
Deb

Thank you all for your responses. 

I'm pretty limited as far as surgeons go unless I end up going over an hour away to the Lansing or Detroit areas. 

I've researched the options and have known from the beginning that RnY just isn't for me.  I know several people personally who have had it done and not had any problems, but I also know a couple who were fine for years and then recently began having major complications.

I truly feel that VSG is right for me.  No messin' with the intestine, no foreign objects there forever, no regular band adjustments...we shall see what can be done, I guess.  I know it sounds horrible, but I'm considering gaining the 15-ish lbs it will take to get me above the 50 BMI, if that's what it takes.

Hi Melissa -

It sounds like you're on the right track.  Have you chosen a surgeon yet?  I think this is an important step in the fight you'll have with your insurance company to get the Sleeve.  My understanding is that there IS a way for BCBS to cover that WLS but you need the help of your surgeon's office to get it done.  I don't know the particulars, but basically you're agreeing to do the first part of the DS (which is the Sleeve) and then you'll go back and have the second part later... but then you just never go back and get the second part done - although that option is always open to you if that's what you decide.   Hurley has just started doing the VSG and that's how I understand they are getting it covered. 

Check out the VSG forum here on OH and I'm sure there will be some folks there that can help you navigate your way through.

Pam

Welcome Melissa,
First of all, this is the place to be if you're looking for first hand information.  I talked to my surgeon regarding VSG and he said he has been able to appeal the decision not to cover it and get it covered.  I considered trying to have him do that, but it's a long process.  He said probably in two years it would be easy to have it approved because then they will have five years of surgeries to study.
I started with my pcp because they should be on board.  Post surgery you do most of your follow up with your pcp...as far as meds etc. (this is what my surgeon tells me).  Make sure you do the research on your surgeon, how many surgeries has he performed and how long has he been doing it?  It may be worth the hour or so drive to get a very competent and experienced surgeon.  I didn't really want to go to downtown Detroit, but the surgeon was the one I wanted.  Get into an orientation/education class if possible.  The bariatric department usually has some sort of conference you can attend.
Good luck to you, and keep us informed.  I have 69 days until my surgery!
Jan

Hi Melissa,

I am also new, I was just approved for lap band surgery and I have BC BS PPO.  I was given a surgery date of July 16th!  It is my understanding with BC BS of MI it depends on the coverage that the employer selects.  I did have to talk to my PCP first and he signed off on the surgery and I took that to the WLC and they took care of everything from there.

Good luck to you!

 

~Brandi

 

I've heard on here 1st hand of it getting covered after appeals. Also the other option as someone stated as the 2part DS but I believe you need to have a BMI of 50. I am also trying to go thru the process of getting the VSG cover with BCBS.  Check the VSG board too!

BCBS is one of the many exceptions to most insurance companies dont cover the VSG. Last I remember, they will cover it as a "1st step to the DS" and if your BMI is over 50 (I think that is the number). Your surgeon needs to be willing to submit it as such.

I would highly recommend you find a surgeon in your area that participates with BCBS and does the DS, RnY and VSG. Contact their office and attend a seminar (most require that you do that before making an appt for a surgical consult). And then go from there. Also check out the VSG forum as there are a number of people on there that have had the VSG covered by BCBS.

Also although you live in MI, do you have BCBS of michigan or BCBS of another state? That could make a difference. When I refer to BCBS, I am meaning BCBS of MI.