BCBS State of TN employees

Does anyone have BCBS state of TN for employees? I have called several times and they have told me a BMI over 40, six months documentated weight loss and behavior modification. My PCP had sent in for predetermination and I received the letter yesterday telling me my insurance did not cover the surgery unless you had a BMI of 60 or greater. My surgeon sent in my chart Aug. 4. So I will wait to see what the insurance tells me then. I am getting a little uneasy since I really need to have gallbladder surgery soon (functioning at 23 % the first of June, maybe less now)I only want to have the one surgery and do both at the same time. Thanks for any help you can give me. Gloria

I have bcbs but it depends which network you are in. I'm in net 2 and so far they said everything is covered and I had them send me the requirements they wanted. I never heard of a requirement of 60bmi.. check which network you have.. then make calls..... also check to see what hospitals and doctors that do the surgery are covered...

I have BCBS State of TN employees.....I called them and they emailed me the qualifications for WLS, more specifically I was inquired as to the lap band surgery. It does state that for certain WLS surgeries you must have a 60 BMI. I hope this clears this matter up for you. This is in response to your e-mail concerning your coverage for lap band bariatric surgery. In-network providers have a $20.00 copay for a PCP or a $25.00 copay for a specialist. If the surgery is approved we pay 100% of the maximum allowable charge. You would have a $100.00 copay for inpatient facility charges. Out-of-Network providers are paid 70% of the maximum allowable charge after the $300.00 calendar year deductible for office visits. If the surgery is approved, you would have an additional $300.00 copay for inpatient facility charges. Your plan requires a predetermination request from the provider that will be performing the lap band bariatric surgery. Eligibility is based on medical necessity. Below are the covered procedures and the criteria that must be sent from the doctor for consideration. * Gastric Banding - involves placing a gastric band around the * outside of the stomach. * Duodenal switch/biliopancreatic bypass - this procedure is * only appropriate for persons with a BMI in excess of 60. * Vertical banded gastroplasty accompanied by gastric banding. * Gastric segmentation along its vertical axis with a roux-en-y * bypass with distal anastomosis placed in the jejunum. * * The criteria that must be sent from the doctor for consideration: * Morbid obesity for at least five years with multiple documented * physician supervised failed weight loss attempts. The * documentation must come from an attending physician who * does not perform bariatric surgery. * Body mass index (BMI) is greater than 40KG/M2 or * At least 45KG (100 pounds) over the ideal body weight or at * least twice the ideal weight. * Body mass index (BMI) is greater than 35KG/M2 with obesity * related co-morbidities at high risk of mortality and morbidity that * are likely to reduce life expectancy. * (A) Coronary artery disease; or * (B) Type 2 diabetes mellitus; or * (C) Obstructive sleep apnea; or * (D) Three or more cardiac risk factors; or * Body mass index (BMI) exceeding 60 for consideration of the duodenal switch/biliopancreatic bypass procedure. * History of failure of medical/dietary therapies. This attempt at conservative management (defined as an inability to lose more than 10% of body weight over a six month period and maintain weight loss) must be within two years prior to surgery, and documented by an attending physician who does not perform bariatric surgery. Please be aware that e-mail is not a secure method of communication. We would like to remind you to keep your information secure, do not send any personal or sensitive data, such as social security number, in any e-mails you may send in response. This information provided today is based on current eligibility and contract limitations. Final determination will be made upon the completion of the processing of your claim. Thank you for your inquiry using our e-mail service. If you have questions or need additional assistance, please contact us at www.BCBST.com or call State Customer Service: (800) 558-6213. State Service BlueCross BlueShield of Tennessee

Lisa, Thank you so much for the information. I had thought about the lap-band but my PCP wanted me to do the bypass since I have a fatty liver and I need to lose at a faster rate. Also I am pre diabetic. Thanks, Gloria

I have not had the surgery yet, but I have a fatty liver and I am currently on Liptor to keep it in check. My sister had a fatty liver and she had the lapband. She had the lap band surgery 1 year ago and has lot 95 pounds.....Her fatty liver is no more......her liver enzmes are perfect now.....she is really encouraging me to have this surgery, because I also am insulin resistant and Lipitor has been show to dramatically increase the risk for stroke in patients with blood sugar problems. I go to my first seminar tomorrow....I am anxious, but nervous too....I want my life back....I was skinny (I mean to the point of looking like I was anorexic), but I ate what I wanted to....After my 3rd child, my hormones went crazy and the pounds added on...After my hysterectomy....it was worse.....I will pray for you, please pray for me. Lisa

Lisa, I went back and reread your e-mail about qualifications and I do not pay a copay, so our insurance must not be the same. I did e-mail them today and asked for the qualifications. Thanks, Gloria