BCBS of MI and VSG approval....

Hello Everyone...

I'm going to try and explain something and hope that I don't just confuse everyone... LOL...

So, I'm going for the sleeve and have BCBS of MI PPO Flexible Blue, my friend also has the same insurance and is doing the sleeve....

She is about a month ahead of me...  she did all the stuff, 6 months of supervised weight loss, all the testing, etc....  when we call BCBSM, and give them the codes of 43843 and 278.01 the customer service people tell us it's covered as long as we follow the guidelines, which we have done...

so my friend is done with all the pre requirements and the surgeon's office submitted everything and she was turned down saying they don't pre authorize that code---what is that all about and then why would the customer service people tell you it is covered?

The surgeon's office told my friend that she could go ahead and have the surgery and then they will submit it and it will probably be covered, but they can't guarantee anything, so she is taking a chance....

So, my question is this---what are your thoughts....  do you think she has a good chance it will get covered, since they tell you it's a covered procedure when you call the customer service people and for some reason they just don't pre authorize that code upfront???  that is what the surgeon's office seems to think....

Another question is do you suggest when I get to that point that I also send in a letter stating why this is the procedure I need, hoping they will see that the sleeve is best for me?  if so do you have any examples I could use?

Sorry this is so long and I hope I don't have everyone confused....  Any thoughts or advice would be greatly appreciated...

Thank you, Candy!

Hey There. I have BCBSMI too! This is what they told me on the customer service side. They do not do Pre-Certifications or Pre-Qualifications for any WLS. You either meet the requirements, make sure you have your doctor look over it, the benefits coordinator look over it and if they feel they can match everything up. They will approve once surgery has been done. However, they will do a Pre-Determination, a pre-determination is what is happening to me. They sent my information on 03/23/09 snail mail to the Providers Pre-Determination Dept. They look it over and pre-determine that the criteria “looks" to be met or not. I have been on the phone daily at 1 p.m. finding out if they have uploaded my information yet. They have not.

Hello ladies,

I was told that in order to qualify for the sleeve [BCBSMI or BCN of MI] your BMI has to be at least 50 or that it would be considered "investigational." That's what I originally wanted was the sleeve but after customer service told me that, I am rethinking my options. They said that it may be covered for BMI under 50 by next year.
Give them a call back and ask them if it is "investigational" and see what they say.

Good luck...

--Prin

Hello,

I have carefirst BCBS with the Federal Government.  They were confusing me also.  The I finally got someone in customer service (Pre Cert.) on the phone.  I was told that your BMI had to be 50 or higher.  Also I was told that all I needed was 2 years of monitored weight management.  I submitted all of my paper work and was approved for the sleeve in 3 days. 

GoodLuck!