VSG - DENIED (BCBS of MA)

Jan 11 - I met with my surgeon one final time before submitting all completed documentation/criteria to Blue Cross Blue Shield of MA. He suggested we wait until after Jan 1, 2010 to submit since the newly created VSG ins.billing code would be in place.

Jan 12th - all documentation was submitted.

Jan 21st - a week and two days later I got the call... 8:05AM-- I saw the physician's office name on my caller ID and I wasn't sure if I wanted to answer or not... but I summoned the courage and did it.  It was Jen the claim coordinator.. super nice and oh-so-helpful! She was sweet and gentle with the news but it wasn't a shock. I knew this would happen. In the back of my heart I was sorta hoping for a shock of a life time by hearing: "you're approved".

She suspects (once she calls BC/BS of MA this morning) that they will state the denial was based on the fact that the VSG procedure is "Investigational".  I've been assured that the written appeal is already underway by Dr.Robinson. A possible peer-to-peer conference call may be requested (my surgeon-vs.-BCBSMA surgical specialist) where they'll discuss WHY/WHY NOT.  Two of SEVERAL appeal factors are going to be: 1) there's an ins. code so why is it "investigational"  Of course not so blunt but in medical/professional terms!     2) I've already undergone a "partial gastrectomy" when I had my LapBand removed.  Jen listed off several other denial objections, including successes and all of the pros that come along with this surgery.

My surgeon is such a nice guy, brilliant, professional, kind... I can go on and on but I know none of that will  get me approved. I will continue to pray that this approval will come thru eventually. Dr.R have talked several times at length both he and I are willing to appeal appeal appeal!! I haven't ruled out RNY in my heart of hearts, my desire is to have the VSG procedure. Due to my workload and other obligations I'm not able to undergo surgery until April/May ish so we'll have a good 2 1/2-3mos of back and forth if need be.

Jen asked that I wait two weeks to hear from her or Dr.R to see what happens next!!!

 

You sound very prepared!! Good luck with your appeal (s).

Martha

Good luck!!  Fingers are crossed that the appeal works in your favor.  I'm not that far behind you.  Have to meet with my GP next week and then expect to meet the surgeon the week after that...so, all in all maybe a month before we submit to my insurance.  I'm prepared for the denial and prepared to appeal if it all goes that way.  I am only interested in the VSG...no LB or RnY for me. 

Again, good luck and please keep us posted!!

Good Luck!! Dr R did my RnY 8 years ago. Jen was a wonderful resource and  a real pitbull when it comes to dealing with the ins company.

Hi-
I too in 2008, wanted the sleeve.  I fought HARD for it.  I appealed all the way to the state and was denied.  I so wanted that sleeve.  BUT

I "settled" for the RNY and you know what....I LOVE MY RNY.  It has done for me what I could not have accomplished on my own.  I am finally under 200 lbs and have lost over 130 since my surgery which was on 9/29/2008.

Whatever happens, take the RNY if all is exhausted...but fight until all appeals are exhausted.  You see though, the problem is that ONCE THEY LET YOU.....the have to let everyone.  It will break the barriers for all ppl who have BCBS of Mass.  Good Luck and fight on.  Whatever happens you will have a great outcome!!

Clare- did you submit your own appeal?? My surgeon is doing mine - I've just been thinking maybe I should be gathering my own/backup appeal info!  What do ya think?

Hi

First the doc did his peer to peer review and that went no where.

I DID ALL THE WORK ON MY OWN...I am still bitter about that as you can see...LOL...he was actually NO HELP to me at all on that...he has it in his head that he did work on my appeal. 

He wrote this letter which was like ONE or TWO sentences and that was it.  He called them and I did the rest of the appeals on my own.  I would be certainly glad to help you.  I think it may be a lost cause.  I had article after article, I had other peoples insurance policies showing THEY covered it...I even showed them (BCBS of MA) that BCBS of MD covered it as an acceptable surgery...told them it was so much cheaper for them ...they did not care...the state denied me too.  It was heartbreaking...I would do it over again though.

In my case, I had diabetes and have A TON of weight to lose..I was 330 now am 199.  I had surgery on 9/29/2008.  SO I am about 1.5 years out and still losing with my RNY.  It is slower these days but still happening.  I think I may have needed the RNY since I had diabetes (gone the day after surgery!!!) 

VSG is truly an AWESOME surgery.  I will help you in any way I can.  Just say the word!!

Clare

Any updates to your fight with BCBS? I just met with Dr. Lautz and decided on the band for 8/9/10 surgery. Called and changed my mind to the VSG but haven't heard if that was possible. Please let me know how things go and I wish you all the luck in the world. Maybe you will pave the road for me

Good Luck!!!