Help---please----if you can!

 got thrown a devastating blow.  They're still working on trying to get some kind of approval, but I can't schedule my surgery.  Insurance (BCBS of Mississippi) won't give a pre-approval letter.  They sent a copy of their medical policy as follows to my insurance coordinator:


Surgical Management The surgical treatment of morbid obesity is considered eligible for coverage for morbidly obese patients whose Benefit Plans indicate specific coverage for these procedures and who meet ALL the following criteria:

1. The patient must have a BMI of 40 or greater, or 35 or greater with documented hypertension, diabetes, or hyperlipidemia; OR be at least 100 pounds over or twice the ideal weight for frame, age, height and sex specified in the most recent Metropolitan Life Insurance Table;
2. Documentation that the condition of morbid obesity has been of at least five years duration;
3. Failed attempts at weight loss have been documented; and
4. No treatable metabolic cause for obesity, such as adrenal or thyroid disorders

The following surgical procedures are considered eligible for coverage for the morbidly obese individual who meets the preceding criteria:

1. Gastric bypass (Gastric restrictive procedure, with gastric bypass for morbid obesity; with short limb [150 cm or less] Roux-en-Y gastroenterostomy) - Gastric bypass (GBP) may be performed with either an open or laparoscopic technique.
2. Vertical-banded gastroplasty  may be performed using an open or laparoscopic approach.
3. Adjustable gastric banding, consisting of an adjustable external band placed around the stomach, is considered medically necessary in the treatment of morbid obesity that has not responded to conservative measures.

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My insurance coordinator was actually going to let me do it, but she's worried they won't pay it because apparently for # 2, my documentation....in my records in 2003, I only had a BMI of 35 and then it pretty much skyrocketed every year after that to 40 or greater, but because I have so few medical records from those inbetween years with weight on them, we can't omit that one even though it's on the border of 5/6 years past. 

So.....while insurance may still cover it, we want to be sure they WILL pay for it and that they can't find any loopholes.  Any suggestions?!?!  I have a BMI of 50 now, but no co-morbidities or anything and I've been overweight my whole life, I guess just not "morbidly obese" until about 2004/2005.  I just feel like it's a crappy road-block since I've been working on getting this since last October.  Arg!!!

I have BCBS of New Jersey and it took 11 weeks for intial approval.  After that, another two weeks for the actual go ahead (final approval) for surgery. 

Have you heard anything from insurance or is it still "in review" ? 

Why is your surgeon's office trying to schedule before you are approved?

We got everything we sent in back from the insurance. 

The surgeon's office ISN'T trying to schedule the surgery.  What we got from the insurance (a copy of the medical policy saying that my group plan covers it as long as I meet the criteria---but they won't say if I've met the criteria or what I've not met).  Since we got that and that's the best we're going to get from my insurance company, they office was trying to decide whether or not to schedule me for surgery because without an approval letter, they're leery about whether or not my insurance will follow through with paying for the procedure. 

Was there a contact person's name on the letter?  I would call them directly and ask to talked to your assigned case worker.  They can probably clear it up for you.  It will help if your insurance person from the surgeon's office does the same.

BCBS was a pain for me too.  After they sent me a letter saying I was eligible for benefits, they tried to tell my surgeon's office that I had not completed all the requirements.  It was total BS and my surgeon's insurance person called them on it because I had actually done more than what was required.  It took a week to get it cleared up but it worked out in the end. 

Honestly, I think they are just trying to make it hard so people will give up.    Stick with it and it'll work out!

Sharon