Blue Shield of CA

BS of CA told me their medical policy lists VSG as "investigative" and is not covered.  Has anyone had luck getting VSG approval from BS of CA, on appeal perhaps?

I just got my denial today from Anthem Blue Cross.  I'm bummed and now I need to decide if I want to appeal.  Good luck with yours

Bummer,  that's my fear,  the paperwork is being prepared but I'm afraid it will be denied.  The doctor said the insurance companies were going to start approving the sleeve this year but from your message i'm afraid Anthem is not one of the forerunners,   WOW  I'm bummed now with you.   Appeal it,  fight it,  i plan to once I get denied.  I really don't want the bypass,  well it's not my first choice.  So sorry,  well keep up the good fight,

I think that is wishful thinking on the part of the doctor.  The fact that the AMA snaps their finger and creates a CPT code for a service doesn't mean the insurance company is going to jump to their command and actually determine the service is not experimental.  The code usually just means it is performed often enough to justify the existence of a specific code.


Generally the medical policies are based on peer reviewed literature (if it were simply a cost thing they would cover the sleeve and not DS for example since the sleeve is much cheaper).  Make sure the doctor includes in your appeal any articles from peer reviewed journals that support the sleeve as being as safe and effective as the standard treatment.

It's so strange,  i called Anthem and they told me that that code 43843 is covered but that they are not the ones who approve or deny,  i have HMO and he said the HMO decide if it is approved or not,,,,, hmmm  more confusing,   my PCP referred me to the gastric surgeon,,,,, but that still doesn't guarantee anything,     i tell you   this is all very frustrating,   well,  gotta go to work now,   lets all keep up the good work and fight on people,  God be with us all  :o)

You didn't say which Anthem (there are quite a few of them, and they are each different since each state is different).

Sounds like you have a capitated HMO product. 

*** Edited to say ****

Just noticed - your header states BS of CA, but in your last response you stated Anthem.  Different companies.

Anthem is BC of CA (Blue Cross).  Completely unrelated - and competitors :)

yes, i have Anthem Blue Cross of California,  HMO.   i think i responded to someone else's blog,  i have to apologize,  this is all very new to me,  before this the only IM i have ever used is at work and so i'm a little out at sea trying to navigate all the different places to look and comment,  my healthcare providers are Health Care Parners,   i spoke to the surgeon's office today to see where the paperwork is at and they said they haven't gotten the psych eval yet from the psychiatrist,  anyway,  i asked what code they were using and she said the new code for 2010- is 43775.  She also said they have to use that code,   i don't know,  i need the sleeve because i have arthritis and have had back pain most of my life so i cannot imaging life without anit-imflammatories. I also have high bp and extremely elevated triglycerides and am pre-diabetic so i'm at a point of crisis and really need some help.  I'm don't know what a capitated HMO product is???