Texas Teacher Insurance

I am a teacher in Texas.  My insurance is BCBS - ActiveCare 2.  I read in another post that Texas state employees have an exclusion.  My benefit book says that they do not cover anything for weight management (unless medically necessary).  Does anyone have any knowledge or experience regarding this insurance and their exclusions?  Anything at all would be of great help.  Thanks in advance!

Hello- I read your posting and wanted to see if I could help. There are alot of policies out there like yours that exclude weight loss surgery. Usually for a large entity such as State of Texas Employees the cost for adding bariatric surgery to the plan can increase their cost by 2-10%. This is why they choose to exclude it. Not fair to you or other like you who are looking for some coverage. I wanted to introduce you to my company - BLIS, Inc. We help patients get access to weight loss surgery. We are currently working in the Texas Market to get some surgeons approved for our program. We offer complication protection coverage for cash pay patients and soon financing for your surgery as well. We also help employer groups give their employees an option to have weight loss surgery with a BLIS Surgeon under a cash pay model with complication protection included. We've been successful setting these deals up and are finding that employer groups like this option very much because it is VERY cost-effective - much more so than covering it in your health plan in the traditional way. You can read more about what we are doing by clicking on some of our links on the left hand side of this forum or by visiting www.bliscompany.com If you'd like to learn more, contact me and I'd be happy to help you! Best wishes to you in your weight loss surgery journey! Billie

Not really sure how that helps.  How can your company help me when I purchase my insurance through the school district?

Hello-
We can help you and other Texas Teacher Employees by working with your employer to help them add bariatric coverage to their plan in a more cost effective way. Right now, they exclude it, because adding it to the plan costs them too much. We would help them set up the benefit of bariatric surgery by direct contracting with BLIS Certified Surgeons in Texas. The contracting would include a price your employer and you would pay to have surgery with complication protection included. You can read some more about this by clicking on the sponsorship links on the left hand side of this forum.
Best,Billie

BC/BS TRS will cover WLS if you meet certain criteria and prove it is medically necessary.

http://medicalpolicy.hcsc.net/medicalpolicy/home?corpEntCd=T X1&corpEntCd=IL1&ctype=POLICY&cat=Surgery&path=/templatedata /medpolicies/POLICY/data/SURGERY/SUR716.003_2008-11-15#hlink

To be considered eligible for benefit coverage of bariatric surgery for treatment of morbid obesity, the following three criteria must be met:

• A diagnosis of morbid obesity, defined as:
  1. Body Mass Index (BMI) of greater than or equal to 40 kg/meter squared; OR
  2. BMI greater than or equal to 35kg/meters squared with at least two (2) of the following co-morbid conditions which have not responded to maximum medical management and which are generally expected to be reversed or improved by bariatric treatment:
     • Hypertension,
     • Dyslipidemia,
     • Diabetes Mellitus,
     • Coronary heart disease,
     • Sleep apnea.

AND

• At least a five-year history of morbid obesity supported by medical record documentation.

AND

• An expectation that appropriate *comprehensive non-surgical treatment has been attempted prior to surgical treatment of morbid obesity

*Comprehensive non-surgical treatment of morbid obesity appropriateness criteria:

• Documentation of active participation in a comprehensive, non-surgical program of weight reduction for at least six (6) months, occurring within the twenty-four (24) months prior to the proposed surgery and preferably unaffiliated with the bariatric surgery program.  (NOTE: The initial BMI at the beginning of a weight reduction program will be used to meet the BMI criteria for the definition of morbid obesity used in this policy.)
• A program will be considered appropriate if it includes the following components:
  1. Nutritional therapy, which may include medical nutrition therapy such as a very low calorie diet such as MediFast and OptiFast or a recognized commercial diet-based weight loss program such as Weigh****chers, Jenny Craig, etc.
  2. Behavior modification or behavioral health interventions.
  3. Counseling and instruction on exercise and increased physical activity.
  4. Ongoing support for lifestyle changes to make and maintain appropriate choices that will reduce health risk factors and improve overall health.

Surgical Program for the treatment of morbid obesity documentation requirements:

• Documentation that growth is completed.  Generally, growth is considered completed by 18 years of age.
• Evaluation by a licensed professional counselor, psychologist or psychiatrist, must be completed within the 12 months preceding the request for surgery.  This evaluation should document:
  1. The absence of significant psychopathology that would hinder the ability of an individual to understand the procedure and comply with medical/surgical recommendations.
  2. Any psychological co-morbidity that could contribute to weight mismanagement or a diagnosed eating disorder.
  3. Patient’s willingness to comply with preoperative and postoperative treatment plans.

Significant relative contraindications for surgical treatment of obesity include:

• Mental handicaps that render a patient unable to understand the rules of eating and exercise and therefore make them unable to participate effectively in the post-operative treatment program.  An example is a patient with malignant hyperphagia (Prader-Willi syndrome), which combines mental retardation with an uncontrollable desire for food.
• Portal hypertension, which is an excessive hazard when laparoscopic gastric surgery is performed.
• An age greater than 65 as for these patients the weight loss is less effective, the duration of benefits are shorter and the risks of the procedures are greater.

GASTRIC RESTRICTIVE PROCEDURES

Gastric bypass using a Roux-en-Y anastomosis (up to and including 150cm) or vertical banded gastroplasty may be eligible for coverage as an open or laparoscopic surgical treatment option for morbid obesity that has not responded to the required conservative measures.

NOTE:  This policy does not address Roux-en-Y Gastric Bypass performed primarily for the treatment of gastric reflux even though this condition may improve following a Roux-en-Y performed for the treatment of morbid obesity.

Gastric bypass using a Billroth II type of anastomosis, popularized as the mini gastric bypass is considered experimental, investigational and unproven as a treatment of morbid obesity.

Adjustable gastric banding (adjustable Lap-Band^®) performed laparoscopically or open and consisting of an external adjustable band placed high around the stomach creating a small pouch and a small stoma, may be eligible for coverage as a surgical treatment option for patients with morbid obesity who meet the eligibility criteria for surgery, including lack of response to the required conservative measures listed above.

BUT BEWARE...

EVEN IF THEY PAY FOR IT... IF YOU HAVE ISSUES... THEY MAKE IT NEARLY IMPOSSIBLE TO GET IT CONVERTED/FIXED.  I AM STILL FIGHTING TO FIX A LAPBAND ISSUE.

Wow!  Thank you so much for all the information.  I feel like I will definitely get approval.  My primary care physician has started me on my 6 month diet in preparation but I kept thinking I might never get approval.  However, I must confess the last bit concerns me somewhat.  I would have thought if they covered me for the surgery, then any complications would be covered as well.  I would like to have the RNY but I know that it comes with greater risks.  Not sure what to do now.  Do you mind if I ask what kind of complications you had with your lapband?