BCBS 24 visits....so discouraging

I just found out after 6 months in the program, that I know need to go for the full 24 months.  This is so discouraging.  How is it (no offense) that people on medicaid can get it, no questions asked, no waiting periods, nothing, but working (not to say that some getting medicaid aren't) people have to jump through hoops and walk on glass?  I am just about ready to give up.  My doctor is supposed to send a letter hoping to appeal their rule, but this just sucks so bad. 

In addition, what really chaps my hyde is I just found out had I changed my medical group when I started, I would have had the surgery done by now, but it's too late to do it now.  Man, this sucks butt big time. 

Does anyone have any ideas or suggestions, my heart (literally) can't take waiting almost a year and a half.  Has this happened to anyone, have they made an exception?  Please help.

What is your situation, meaning weight-wise? Do you have a BMI over 40? If not, do you have a BMI of 35-39 with diabetes, high blood pressure, or sleep apnea? 

Get this one, I have GERD so bad that it has eaten a hole in my esophagus. I suffer with heart burn so badly that I literally feel like I am having a heart attack on a nightly basis (mind you, I am only 38 years old). My BMI was 38.5 and they had me go through the 6 months of preop just to tell me that my GERD was not significant enough to cover my WLS. I had been on meds for 10 years with no help whatsoever, EGDs, etc. So, I have my last preop appt and I actually gained 5 pounds, which is very, very bad. They don't want you to gain weight because then you show that you probably cant keep to a bariatric diet afterwards.

I get a call from my surgeon telling me that I have to have another weigh in (2 months after all my preop appointments), and she asked if I thought I had gained more weight. I told her probably not enough to bring my BMI up to 40 for my insurance to consider approval, and she actually sounded like it was hopeless!! So, I ate like a pig for 2 days, weighed in, and ended up with a BMI of 40.2. My insurance approved me 2 days later. What the heck? I am glad that I am finally approved, but really? I feel like I had to slip downhill in order to get them to approve me. You think they would have been happy with me losing weight, not gaining it!

Hi Lori,

Yes my BMI is well over 40, 59 to be exact.  Fortunately I don't have sleep apnea or diabetes, but I do have a little high blood pressure.  So far I was told that we can appeal, so that's what my regular doc and I are doing.  So far I haven't heard anything back yet.  But I am working on it.  I am glad to here that yours went through, I too am a young woman (36) and this just sucks so bad.  

Congrats to you, I hope that some of your good fortune rubs off on me.

 
If you are going to appeal it be sure to include the ASMBS study showing that these 6+ month pre op diets are of no use.  You can find it at the ASMBS website.

Definitely appeal that one! I can't believe they are doing this to you. Given your young age, you have many, many years of health issues that may come up due to obesity.

One thing I did was send a letter that I wrote myself, I think it gave them a more heartfelt outlook on what I felt I am going through. i also had 2 other physicians that I had seen in the past to write letters of recommendations, both stating that they felt this surgery would help my current issues and prevent future ones.  

Oh, and in my letter, I told the insurance company not only my issues, but any possible obesity-related family health problems, because these can easily be passed down to you later in life.

Good luck, and keep us posted!

Lori,

That is a great idea.  I am going to work on my letter as well, hell, I'll do a video if I have to.  I never thought to do a letter.  I will call my insurance medical group today and find out who I should address my letter too. 

Thanks a lot Lori.  When I first found out about the waiting period, I cried.  I felt as if all hope was lost, but thanks because you have given me hope.  I'm not saying I was going to give up, I feelings were just so deflated and disappointed by it.  But I wont give up and I definitely will keep you posted. 

Thanks again. 

Kina.

I was denied 2x in 2009 because I was to small (BMI 38) and then in December I tried again because not trying I got to a BMI of 40.  I have been denied 2x in February and I have 3 nut. visits.  Last one is Monday April 16th then they are going to submit again. Now I am under 40 because I have been following the directions.  I am not getting my hopes up.  If I get denied again I will just throw in the towel and realize I am ment to be fat forever.  I have BCBS Illinois and I meet all the requirements they just are jack a**.

Don't give up.  I felt the same way.  I had BCBS and had Medicaid as a supplemental.  I didn't attempt to apply with BCBS because they informed me ahead of time that with the medical group I had, I was required to undergo weight managment for 24 months before I would be considered for the surgery.  So, I left BCBS and went to my medicaid full time and now I am able to have the surgery.

I'll never understand why it's easier with Medicaid than most insurance, but that's just the way it goes. 

Don't give up, if the surgery does not work, the nurt vists appears to be if you're losing your BMI.  I will pray for you.  Good Luck. 

Thanks a lot Rebecca.

Yes, that 24 visits was a long time.  The only way I would have been approved by BCSBS would have been my PCP appealing on my behave, but you know how some doctors are.  He was taking his own sweet time, and I never heard from him regarding the matter.  So with when I spoke with the surgeon's office, she informed me that Medicaid in Illinois is more laid back regarding approval, virtually you only need your physician's recommendation, I would get approved.  BCBS was my primary and Medicaid was my supplemental, and I had my employer drop me from BCBS and and now Medicaid is my primary and now I have appointment tomorrow with my surgeon.  I am so excited.  Hold on, cuz a change is coming. 

Thanks for the wishes and good luck to you too dear.  Keep me posted on you progress as I will do the same. 

24 months?  That's a really long time.  My insurance required 6 months and I know people here (in Arizona) who've had wls with medicaid and they had to wait 6 months too and jump through lots of other hoops, but 24 months seems like so long.  Do you have problems that could justify your doctor asking for an exception?  

I don't have much advice but to say I'm so sorry.  I do understand.  I had insurance that I did all the preop stuff (cardiologist, pulmonologist, nutritionist, blood work, psych eval, 6 months of doctor supervised visits) and then was dropped right before we submitted.  I was hysterical.  Now, a year and half later with new insurance, I am scheduled for April 27.  Good luck to you!  I really wish you the best.