Warning - Dr. Moran was not upfront
I also have Dr. Moran and Janell gave me a copy of BCBS's policy with that information in it. I asked her if most people were approved that were insured by BCBS. She did tell me that someone just got denied for that reason (maybe that was you?).
I am concerned about that and was told up front, but I decided to go on with the testing anyway. I also called BCBS and spoke to a CSR and she told me that if my BMI falls below 40 in 4 of the past 5 years I would just need proof of any co morbid conditions. Could it be that your BMI is not over 40 and has not been??? If I were you I would appeal, that is my plan if I don't get approved.
Hi and thanks for your response. Yes, Janell gave me a copy of the BCBS requirements for lapband surgery. I was told that my BMI had to be 35 or more and that I would have to have additional medical conditions as well. My BMI is 37.5 and I have high blood pressure and high cholesterol. My BMI has never been in the 40's. My weight has ranged from 160 - 218 in the past 5 years. I lost 30 or so pounds after giving to my birth in 2003. At the time of his birth I was 203 lbs. I do not remember the BCBS paper stating that my BMI could not fall below 35 during the past five years. I know that BCBS wanted a five year weight history. I just feel that all the testing was not necessary if I did not meet the criteria to begin with. I will consider appealing the decision and see what happens. Good luck to you! Karen
I, too have BCBS state teachers emp. I never dropped below 35 in the past 5 years, but I do have health issues. Before I shelled out any money and even seriously thought about having this surgery, I called my insurance company and asked what they covered, in detail. I agree that the Dr. office should have gave you a list of what your insurance covers, but that would only come after the initial consult, and the cost of that. Hopefully you will appeal. Good luck!
Hi and thanks for your response. I did call the insurance company before my initial consultation with Dr. Moran. I was told that weight loss surgery was covered if recommended by a doctor and that if my BMI was higher than 35 with additional medical conditions. I have high blood pressure and high cholesterol. They did not say anything about it being below 35 in the past five years. I do think Dr. Moran should have told me about this before I spent additional money getting a whole bunch of tests done. I do understand that the initial consultation should be part of the process but nothing should have been done further until the insurance company made a decision. I was thinking that the office took care of this part first but later found out that after all my testing was done that this information was then submitted to the insurance company. This seems like a backwards approach. I will consider appealing the decision and see what happens. Did you have the surgery? Are you happy with the results? Karen
Wow I have to say as a patient it's very hard to deal with but as an employee of a bariatric surgeon it's hard to always know every policy. I know BCBS NC inside and out. I try to always let the patients know before they leave my office what is needed. IF the BMI is between 35 and 40 when they sit and talk to me I make sure they have a co-morbidity. I have never even thought to tell them that if it falls below 35 that they wouldn't get approved. So thank you for bringing that to my attn. One problem is that I don't normally have the weight history when I am talking to them and I don't normally figure the BMI before I send it, at any one time I am helping 150 - 200 patients. So it's very hard. As a patient who went through this I know it's hard, that is why now in my job when a denial comes in I take it personally. I know what it's like to be over weight and I get mad at insurnace companies all the time.
So here is what I would suggest to our patients....request a peer to peer, maybe not w/ your surgeon but w/ your pcp and BCBS. Your pcp knows your history knows how things are getting worse and so on...so they could probably fight your case better. If that is denied...appeal, keep appealing until you win. Write a great letter, I am sure people out here will give you pointers. I will tell you the first appeal stays w/ in BCBS so it will more then likely be denied again but the 2nd one starts going outside the company. So appeal let them know where you life is headed, let them know the family history of obesity if there is any. Don't stop here. Ask for help from your surgeons office.
I know it's been asked...what year did the bmi drop below 35? They are looking for the last 4 - 5 years so in 07 that is weights from 02 - 06...if it's 02 and 03 weight until next year and apply again using weights form 04 - 07. Does this make sense?
Hang in there and I wish there was more I could do and I know nothing is going to make it better foryou but don't give up. If this is what you want keep fighting it go for it and you will win. Have the will to win and you will get there.
Good Luck!
Hi! Thank you so much for your nice response. I really do appreciate the time you took to write it. I figured that BCBS State Insurance was one of the most popular insurance plans so I thought the office would know everything there was to know. If I knew it would have helped to have my five year weight history in advance of the initial consultation, I would have done so. My weight has ranged from 160 to 220 lbs. in the past 10 years. My weight problem started after having my first child in 1997. I gained 60 lbs. I was initially 135 lbs. I have 3 children. In 2003 I had my last son. I was 203 lbs. right before delivery. I went on LA Weight Loss and lost about 30 lbs. My current BMI is 37.5. I am five feet four inches. It took me about one year to gain the weight back again. I am definitely considering appealing the decision since I do love to write and make a point. There was some question as to having some of my weight history in 2002 (I was pregnant at the time). My weight would have been recorded by my OB/GYN during that time. By the way, what does pcp stand for? What is a peer to peer review? How is it arranged? I guess I will begin by sending a letter of appeal to BCBS and see what happens. Thanks again for writing to me!! Karen
Hi Karen -
I also am a patient of Dr. Moran's. When I attended the seminar he did say that 35-39 is kindda a "grey area". It really just depends on the insurance directors mood, if ya ask me. LOL!
My bmi is 37.8/38 "gray area". I have UHC and submitted recently and was denied. I plan on appealing till my fingers bleed! First, I'm going back to my PCP to get a little more ammo. Then I will also do a sleep study, see if that comes up with anything?
Sorry to hear that you had to put so much $$ out of pocket. My co-pays are only 10$ no matter who I see (excepy NUT was 130$) I would probably be more ticked if I put out that kind of $$. BUT, look at it this way.......if you don't appeal.....your kindda just throwing that $$ away. APPEAL, what do you have to lose?
I'm a "squeaky wheel" LOL!
Best Wishes
Hi Karen -
I also am a patient of Dr. Moran's. When I attended the seminar he did say that 35-39 is kindda a "grey area". It really just depends on the insurance directors mood, if ya ask me. LOL!
My bmi is 37.8/38 "gray area". I have UHC and submitted recently and was denied. I plan on appealing till my fingers bleed! First, I'm going back to my PCP to get a little more ammo. Then I will also do a sleep study, see if that comes up with anything?
Sorry to hear that you had to put so much $$ out of pocket. My co-pays are only 10$ no matter who I see (excepy NUT was 130$) I would probably be more ticked if I put out that kind of $$. BUT, look at it this way.......if you don't appeal.....your kindda just throwing that $$ away. APPEAL, what do you have to lose?
I'm a "squeaky wheel" LOL!
Best Wishes
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