BCBS OF TX
Hi all. I am posting a *slight* update to my previous post/ status.
Here is what has gone on so far:
4/20- paperwork submitted by surgeon's office for BCBS TX approval
4/22- letter printed by BCBS TX asking for clarification on the procedure to be performed due to a conflict with the procedure code requested (RNY) and the notes from my PCP/Psychologist (who wrote "sleeve" down at some point during one of my visits with them). I receieved this letter on 4/28.
4/28- received the above letter from BCBS TX and put a call in to the surgeon's insurance coordinator regarding the request.
4/29- surgeon's ins. coordinator spoke to BCBS TX to verify the procedure code (RNY) and clarifiy any confusion. BCBS TX did verify that they have everything/ all info they need to make the decision and stated that we will hear back "very soon".
Could be good, could be bad...I guess! I will update again when I hear something! It does seem that if there hadn't been any confusion regarding my doctor's notes, I may have heard something back within 8 days (4/20 to 4/28). Now it may be another 8 days.
Here is what has gone on so far:
4/20- paperwork submitted by surgeon's office for BCBS TX approval
4/22- letter printed by BCBS TX asking for clarification on the procedure to be performed due to a conflict with the procedure code requested (RNY) and the notes from my PCP/Psychologist (who wrote "sleeve" down at some point during one of my visits with them). I receieved this letter on 4/28.
4/28- received the above letter from BCBS TX and put a call in to the surgeon's insurance coordinator regarding the request.
4/29- surgeon's ins. coordinator spoke to BCBS TX to verify the procedure code (RNY) and clarifiy any confusion. BCBS TX did verify that they have everything/ all info they need to make the decision and stated that we will hear back "very soon".
Could be good, could be bad...I guess! I will update again when I hear something! It does seem that if there hadn't been any confusion regarding my doctor's notes, I may have heard something back within 8 days (4/20 to 4/28). Now it may be another 8 days.
Ok Soooo here's my update.....BCBS deined me saying I had to follow the insuracne requirments for 2008 since that is when Ihad my Band done.....But the DID NOT pay for it and I did not have them until 2009 so now they want 5 yrs of Dr notes saying I was Obese..............They only stuff I have is in 2000 when I had my tubes tied saying I weighted 250 pounds and was obese....I am pretty healthy and dont go to the Dr the most I have been to the Dr was when I got the lapband and since I was self pay I didnt have to do the whole 5 yr obese stuff....Calling the WLS Dr tom maybe he can help....If anybody has any advise pleaselet me know...........Thanks Shannon
Here's my update: I'm APPROVED for the RNY !! Yay!!! 
So, to update my approval process timeline:
Here is what has gone on so far:
4/20- paperwork submitted by surgeon's office for BCBS TX approval
4/22- letter printed by BCBS TX asking for clarification on the procedure to be performed due to a conflict with the procedure code requested (RNY) and the notes from my PCP/Psychologist (who wrote "sleeve" down at some point during one of my visits with them). I received this letter on 4/28.
4/28- received the above letter from BCBS TX and put a call in to the surgeon's insurance coordinator regarding the request.
4/29- surgeon's ins. coordinator spoke to BCBS TX to verify the procedure code (RNY) and clarifiy any confusion. BCBS TX did verify that they have everything/ all info they need to make the decision and stated that we will hear back "very soon".
5/7/10- Called BCBS TX to check on status and was told I was APPROVED for the RNY. They have sent the approval letter (dated 5/6/10) to me and to my surgeon!!! Yay!!! Now I get to call their office on Monday to schedule out all of my pre-surgery appointments!!!
I also wanted to mention to all of you that I did not/ do not have any comorbidities. I was concerned that BCBS TX might look for some of those when going over my paperwork for approval. It turns out that they were only looking for the exact things they listed in their requirements letter. So, if you just follow that to the letter, everything should be fine! My only medical problems other than being obese are PCOS, insulin resistance, and hypothyroidism, which are not considered comorbiditites.
All of this may be more than you all want to hear, but I wish that others would be *very* detailed in their posts so that we can get all the information that we need! I'd rather see too much than not enough!
Thanks to everyone who posts their experiences and good luck to those who are in any stage of this process!
So, to update my approval process timeline:
Here is what has gone on so far:
4/20- paperwork submitted by surgeon's office for BCBS TX approval
4/22- letter printed by BCBS TX asking for clarification on the procedure to be performed due to a conflict with the procedure code requested (RNY) and the notes from my PCP/Psychologist (who wrote "sleeve" down at some point during one of my visits with them). I received this letter on 4/28.
4/28- received the above letter from BCBS TX and put a call in to the surgeon's insurance coordinator regarding the request.
4/29- surgeon's ins. coordinator spoke to BCBS TX to verify the procedure code (RNY) and clarifiy any confusion. BCBS TX did verify that they have everything/ all info they need to make the decision and stated that we will hear back "very soon".
5/7/10- Called BCBS TX to check on status and was told I was APPROVED for the RNY. They have sent the approval letter (dated 5/6/10) to me and to my surgeon!!! Yay!!! Now I get to call their office on Monday to schedule out all of my pre-surgery appointments!!!
I also wanted to mention to all of you that I did not/ do not have any comorbidities. I was concerned that BCBS TX might look for some of those when going over my paperwork for approval. It turns out that they were only looking for the exact things they listed in their requirements letter. So, if you just follow that to the letter, everything should be fine! My only medical problems other than being obese are PCOS, insulin resistance, and hypothyroidism, which are not considered comorbiditites.
All of this may be more than you all want to hear, but I wish that others would be *very* detailed in their posts so that we can get all the information that we need! I'd rather see too much than not enough!
Thanks to everyone who posts their experiences and good luck to those who are in any stage of this process!
Hi Thintopia first off CONGRATS on your approval.......... Second I have done everything in there policy and they still wanted more info. The Nurse called Friday and spoke to someone and she said not to submitt what they have requested and took notes of what my nurse told her....so its back in review again....Im trying to have the band taken out and the bypass done and i met ALL the certria not sure what is going on with them.........hope to hear something soon............
Ladies- Thanks so much for your good wishes!
Lousianamama, I am so sorry that you are still having a hard time with the insurance. Obviously, they are still focused on the fact that you have had a WLS previously.
One thing I did consider was to call the insurance and ask them to for a copy of the whole entire policy for your plan. I did not end up doing this, but I did think about it when I got a snappy sounding email from my surgeon's office about how they "follow the policy exactly". I was wondering where they got a copy of the policy...I never had one. All I had was the measly benefits guide/booklet that my employer hands out during enrollment. I wanted to see the fine print!! That must be how they are able to deny some requests. That's all I can think of. Otherwise, you might consider asking the insurance for a Case Manager who can help you with your questions. At least they might have more information for you than the regular customer service reps you get when you call!
Also, in reading other posts, I've seen that people in other states have commented on appealing to their state insurance regulatory board. That might be a last resort for you.
My bottom line advice is that the surgeon's office may not have all the information. I had to start taking things into my own hands once I got the impression that they may not have the sense of urgency that I expected them to have!
I wish you all the best with the rest of your appeal. Hang in there and do not give up!
Lousianamama, I am so sorry that you are still having a hard time with the insurance. Obviously, they are still focused on the fact that you have had a WLS previously.
One thing I did consider was to call the insurance and ask them to for a copy of the whole entire policy for your plan. I did not end up doing this, but I did think about it when I got a snappy sounding email from my surgeon's office about how they "follow the policy exactly". I was wondering where they got a copy of the policy...I never had one. All I had was the measly benefits guide/booklet that my employer hands out during enrollment. I wanted to see the fine print!! That must be how they are able to deny some requests. That's all I can think of. Otherwise, you might consider asking the insurance for a Case Manager who can help you with your questions. At least they might have more information for you than the regular customer service reps you get when you call!
Also, in reading other posts, I've seen that people in other states have commented on appealing to their state insurance regulatory board. That might be a last resort for you.
My bottom line advice is that the surgeon's office may not have all the information. I had to start taking things into my own hands once I got the impression that they may not have the sense of urgency that I expected them to have!
I wish you all the best with the rest of your appeal. Hang in there and do not give up!
I just wanted to let everyone know I have been APPROVED!!!! My Drs office called in on May 7th and I called Wed the 12th and it was APPROVED for the BYPASS but they denied paying for the BAND to be taken out.....Waiting to see if I have to pay anything and if soo how much before I set my date.....oh it was APPROVED the same day the DRS office called....Thats FUNNY................EXCITED.... Thanks for all comments.......
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