Question for Diamond Girl
Hi Diamond Girl!
You replied to my recent question about the possibility of BCBS paying for a VSG or DS. I know that you successfully appealed BCBS's denial for a DS, and I'd like to know more about how you did this. How many appeals did it take, and how long was the process? Were there any special medical conditions that you asked them to consider in your appeal?
Oh - and I just saw your new avatar. You're looking Babe-a-licious!!
Thanks,
Naomi
You replied to my recent question about the possibility of BCBS paying for a VSG or DS. I know that you successfully appealed BCBS's denial for a DS, and I'd like to know more about how you did this. How many appeals did it take, and how long was the process? Were there any special medical conditions that you asked them to consider in your appeal?
Oh - and I just saw your new avatar. You're looking Babe-a-licious!!
Thanks,
Naomi
Hi - I noticed on BCBS' policy page that the requirements for DS are changing as of 8/20/09. Unfortunately the BMI requirement is still 50. At least they took away the language about serious co-morbidity and reviewing DS on a case by case basis.
Bariatric Surgery (formerly Surgery for Morbid Obesity)
Bariatric Surgery (formerly Surgery for Morbid Obesity)
- The following additional procedure may be considered medically necessary in the treatment of obesity when patient selection criteria have been met:
- Open or laparoscopic biliopancreatic bypass with duodenal switch in patients with a BMI ≥ 50.
- The following additional procedures are considered investigative and not medically necessary:
- Long-limb gastric bypass procedure ((i.e., > 150 cm);
- Endoscopic procedures (e.g., insertion of the Stomaphyx™ device, sclerosing endotherapy) to treat weight gain after bariatric surgery or to remedy large gastric stoma or large gastric pouches;
- Bariatric surgery (any procedure) solely as a cure for type 2 diabetes mellitus.
- The remainder of the policy is unchanged.
- Prior authorization: Yes.
Naomi,
A couple things to keep in mind with BCBS of MN.
The above change noted by AJordan may or may not apply to your specific policy. Please be sure that you have a copy of your specific policy. But I do think it is more in your favor if the policy is changing across the board as far as the "investigative" language goes.
Also, you have 3 appeals with any case in a year's time. I used 2 of the 3. It was on the 2nd appeal that I won. Typically the first two are written appeals and the 3rd would be a verbal peer-to-peer with your surgeon and the insurance rep.
We have a law firm in Minnesota writing the appeals for those wishing to go with the DS and who have BCBS of MN. I will send you their contact information via PM. Please utilize them vs. the surgeon's office. The appeal will be more thorough and it will have more background information attached and case study vs. the appeal the surgeon's office would put together.
I got my BCBS coverage on 1/1/08. I then started my 6 months of doctor supervised diet visits (req'd by insurance). During those 6 months, I also went ahead and had my psych eval done to ensure that was ready to go right away. After my last PCP visit in June, my surgeon's office sent it all in for approval. It was denied, of course. Then I turned it over to the legal team. However, I needed a BMI of 50 documented, along with co-morbidiities. I worked hard to get sleep apnea and Type II diabetes documented. At the time of my weigh in for the sleep study, a BMI of 50 was documented. While this was going on, the first appeal had been submitted and was based on case study of why it is no longer investigational. Once that denial came back, we went in with all the new stuff meeting their requirements. I also wrote a personal letter and included pictures of my children and husband, to personalize the second appeal. Then the legal team put it all together and sent it off. And we won. I won that appeal and within a week was having my surgery because we were already to December and I had already met my deductible for the year, so I wanted surgery before the end of 2008. I should also mention to you that I had been laid off during all of this, so I was paying Cobra to keep that BCBS coverage. But I would tell you that even despite all theose hurdles, it was well worth the fight.
Best wishes!!! Please keep me posted on how you decide to move forward and if there's anything I can help you with beyond sharing my appeal information.
And thank you for the compliment BTW!
A couple things to keep in mind with BCBS of MN.
The above change noted by AJordan may or may not apply to your specific policy. Please be sure that you have a copy of your specific policy. But I do think it is more in your favor if the policy is changing across the board as far as the "investigative" language goes.
Also, you have 3 appeals with any case in a year's time. I used 2 of the 3. It was on the 2nd appeal that I won. Typically the first two are written appeals and the 3rd would be a verbal peer-to-peer with your surgeon and the insurance rep.
We have a law firm in Minnesota writing the appeals for those wishing to go with the DS and who have BCBS of MN. I will send you their contact information via PM. Please utilize them vs. the surgeon's office. The appeal will be more thorough and it will have more background information attached and case study vs. the appeal the surgeon's office would put together.
I got my BCBS coverage on 1/1/08. I then started my 6 months of doctor supervised diet visits (req'd by insurance). During those 6 months, I also went ahead and had my psych eval done to ensure that was ready to go right away. After my last PCP visit in June, my surgeon's office sent it all in for approval. It was denied, of course. Then I turned it over to the legal team. However, I needed a BMI of 50 documented, along with co-morbidiities. I worked hard to get sleep apnea and Type II diabetes documented. At the time of my weigh in for the sleep study, a BMI of 50 was documented. While this was going on, the first appeal had been submitted and was based on case study of why it is no longer investigational. Once that denial came back, we went in with all the new stuff meeting their requirements. I also wrote a personal letter and included pictures of my children and husband, to personalize the second appeal. Then the legal team put it all together and sent it off. And we won. I won that appeal and within a week was having my surgery because we were already to December and I had already met my deductible for the year, so I wanted surgery before the end of 2008. I should also mention to you that I had been laid off during all of this, so I was paying Cobra to keep that BCBS coverage. But I would tell you that even despite all theose hurdles, it was well worth the fight.
Best wishes!!! Please keep me posted on how you decide to move forward and if there's anything I can help you with beyond sharing my appeal information.
And thank you for the compliment BTW!
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