BMI 41, denised VSG...
My BMI is 41 and I was denied the VSG. My insurance states a BMI of 50 for the VSG.
CareFirst is a BCBS policy.
I can get the bypass or band so Im not so upset.
Also another Dr will do a switch without the switch and thus I get the VSG I want.
What was your BMI at the time of approval if you had a VSG.
CareFirst is a BCBS policy.
I can get the bypass or band so Im not so upset.
Also another Dr will do a switch without the switch and thus I get the VSG I want.
What was your BMI at the time of approval if you had a VSG.
A lot depends on the comorbidities you are facing. Both the VSG and the RNY are proven surgeries. Both can be converted to the DS later if need be. It's a tough choice but you aren't going into this haphazard...You've thought about it for a while...Looked at it from all angles. I think you'll come up with the right choice and right doctor. Just my thoughts. Brian
Do your research on why the VSG is the best option for you and your lifestyle. Get with your surgeon and make a case for an appeal and submit an appeal. Setteling for a surgery is a major mistake. YOu need to learn to be your own advocate when it comes to your health and push for what you believe is best for you.
I haven't heard of a VSG requiring a higher BMI than the RNY as the VSG is purely restrictive.
I haven't heard of a VSG requiring a higher BMI than the RNY as the VSG is purely restrictive.
Paul C.
First 5K 9/27/20 46:32 - 11 weeks post op (PR 28:55 8/15/11)
First 10K 7/04/2011 1:03 First 15K 9/18/2011 1:37
First Half Marathon 10/02/2011 2:27:44 (PR 2:24:35)
First Half Ironman 9/30/12 7:32:04
First 5K 9/27/20 46:32 - 11 weeks post op (PR 28:55 8/15/11)
First 10K 7/04/2011 1:03 First 15K 9/18/2011 1:37
First Half Marathon 10/02/2011 2:27:44 (PR 2:24:35)
First Half Ironman 9/30/12 7:32:04
The thing to remember here is that the policy is dependent on your companies choices, not BCBS. Its like car insurance you can get basic liability at 25/50 or you can pay more and get it at 100/300.If your company decides to say BMI of 50, then BCBS will draw up your benefits package based on their request. This was explained to my by a friend of mine who is a product specialist at BCBS.
I have BCBS of Mo and according to our policy weight loss surgery uses the 40 BMI baseline or 35 with co morbities. In my case our policy doesn't cover VSG surgery it isnt "Medically Necessary", but as soon as I got all my other requirements done, sleep study, shrink report, docs approvals, etc. they approved it.
Now one month later I am down 35 pounds, if you contact BCBS ask them to send you a copy of your plan document. Its explains all the different coverages and is like 50 pages. Then you can see the specific about weightloss surgery, when it comes to "Medically Necessary" you can get these items approved by getting docs to say it is medically necessary and why. Then you can also ask your surgeon to do a peer review with a doc at BCBS to explain why it is and they will usually approve.
G
I have BCBS of Mo and according to our policy weight loss surgery uses the 40 BMI baseline or 35 with co morbities. In my case our policy doesn't cover VSG surgery it isnt "Medically Necessary", but as soon as I got all my other requirements done, sleep study, shrink report, docs approvals, etc. they approved it.
Now one month later I am down 35 pounds, if you contact BCBS ask them to send you a copy of your plan document. Its explains all the different coverages and is like 50 pages. Then you can see the specific about weightloss surgery, when it comes to "Medically Necessary" you can get these items approved by getting docs to say it is medically necessary and why. Then you can also ask your surgeon to do a peer review with a doc at BCBS to explain why it is and they will usually approve.
G
My suggestion is to appeal with your insurance company. Many have appealed and won their case.
I think each insurance company is a bit different in their requirements. Cigna (last time I checked) requirement was >40 with no comorbidities (SP) and/or >30 with at least two comorbidities (SP).
I was a BMI of 49.8 (357 lbs)for my initial consult (which is the number they submitted to insurance) and BMI of 41 (307 lbs) on the day of my surgery.
I would post on the VSG board. Several people have sample appeal letters that you can use for your appeal letter.
Last year this time most insurance companies weren't signing off on the VSG at all. Many have opened up this year. You have nothing to loose by appealing.
***Edit - Here's a link to a posting today about a BCBS person winning an appeal.
http://www.obesityhelp.com/forums/vsg/4370590/APPEAL-WON-Fed -BCBS/
I think each insurance company is a bit different in their requirements. Cigna (last time I checked) requirement was >40 with no comorbidities (SP) and/or >30 with at least two comorbidities (SP).
I was a BMI of 49.8 (357 lbs)for my initial consult (which is the number they submitted to insurance) and BMI of 41 (307 lbs) on the day of my surgery.
I would post on the VSG board. Several people have sample appeal letters that you can use for your appeal letter.
Last year this time most insurance companies weren't signing off on the VSG at all. Many have opened up this year. You have nothing to loose by appealing.
***Edit - Here's a link to a posting today about a BCBS person winning an appeal.
http://www.obesityhelp.com/forums/vsg/4370590/APPEAL-WON-Fed -BCBS/
Highest Weight: 380 Consult Weight: 357 Surgery Weight: 309
Goal Weight: 220 (9/29/10) Revised Goal Range 215-220 Current Weight: 224
Plastics: Circumferential Lower Body Lift - 11/18/2011
Gynecomastia - 6/14/2012
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