Anyone with BCBS IL insurance in bloomington il?

I had RNY about 4 years ago. I lost 125 lbs and now have gained 50 lbs back (my BMI is now 41.6). I called BCBS IL and told them i was interested in getting a revision. Although I am not an expert, I felt I was teaching my insurer of the RNY surgery and revisions.

After 45mins on the phone and a lot of being on hold, she tells me that they are no longer covering gastric bypass surgery, however if they would cover if there were complications. I asked what those complications would be and she had no answer.

I couldnt tell if she didnt understand me or was just being evasive. 

I had to deal with this with my previous insurer many years ago due to ignorance or just them just saying they dont do the surgery (even if they actually do).

Has anyone in bloomington il who has BCBS had weight loss surgery (their first or revision)?

If you have had the revision surgery, can you give details- like what exactly did you have to do (letters/history), did you have to have a medically supervised diet for 12 months, what was your BMI, what surgery did you have the second time, where did you go, was the second surgery successful, etc.

I have an appointment with my general physician in late June and with the Kane group this coming up Sat.

any help/advice would be greatly appreciated.

thanks

Hi Trilla,

I have BCBS (some offices call it of IL, some of NJ).  Anyway, it actually depends on what your company has in it's documentation.
What I can share with you is my story.
I have RNY in October, 2004.  I lost about 125 pounds, and then stopped.  I failed to make the necessary changes in my life, due in part to bad advice from the surgeon I chose, and in part to my lack of effort in educating myself before I'd done the damage.
The original surgeon (Bariatric Treatment Centers) closed in Illinois.  I knew i had a problem.  Two years ago I located a surgeon (Dr. Alverdy out of University of Chicago Hospitals) who is considered to be one of the best in the area, and possibly the country and asked if he would consider taking me into his program and helping reduce the size of my stomach, because I could tell that I had no restriction.  He arranged for me to see him, arranged for a test to determine the size of my pouch, and found that the pouch (at that time) wasn't horribly stretched, but that the stoma was stretched enough to keep me from feeling full on a low calorie diet - thus making it impossible for me to ever succeed at finishing the weight loss.  He accepted me into the program and two years later sumitted a request to BCBS to perform a revision from RNY to DS.  I was surprised by this, but researched it and accepted it. BCBS approved the surgery based solely on the letter from Dr. Alverdy - my guess is that the stretching was classified as a complication.

My surgery was May 18th.  When I woke up I found out that he was unable to perform the DS because of too much scarring and my intestines being in the wrong place, but he restored my RNY, so that my insides are once again very small pouch and tiny stoma.  If I follow the information I now have, I will succeed.

I really hope this helps you.  Good luck!  Let the doctor's office help you with the insurance company.

 This is of great help. thank you so much. I actually wrote an email to him today asking about if he had any experience with revision surgery since i hadnt seen it anywhere.

I was wondering, why did you wait 2 years? is there a program you must go through before he will do the surgery? it took a lot for me to do the surgery and i am in the mind set to get it done.

Thanks so much for letting me know your experience. I hope you the very best with your surgery!

Joanne

Hi,
I waited so long for several reasons.  One was because his office isn't the most efficient office you could ask for - you have to really push them to get any kind of response.  That being said, if I had been more interested in moving faster, I'd have pushed harder.  I really had some things to get straight in my head in that time frame (I'm not there, but am closer) because I knew that this second chance would be a tremendous gift, and I couldn't expect to get it again.
I also thought I was going to be self pay.  I never believed that the insurance would cover a second surgery (so you can understand my incredible surprise when they did!). So I had to wait until I had the money to pay for the surgery.  I thought I was doing something other than what we ended up doing - I asked for the ROSE procedure, he suggested the band, and it wasn't until the letter was sent to the insurance company that I understood he wanted to do the DS - which he felt very strongly was my BEST chance of long term success.
Now I have a fixed RNY, and am very happy with it.  This is what I learned most about, what I understand the life changes to be, and I am going to make it work.  Dr. Alverdy is wonderful.  His program is very comprehensive.  He is as motivated (as his staff is) to ensure that you succeed as you are - maybe more so.  In the hospital I got a lecture that if I failed to follow the rules I would stretch the pouch again and be right back where I started.  He stressed (unlike the first surgeon who never mentioned this) that he had given me a tool and that it was MY job to use it properly and respect it.  (funny - you know the commercial "RESPECT THE POUCH" - I think this needs to become my catch phrase).

Good luck - don't give up.  :)

I called Dr. Alverdy's office today and Stephanie emailed me a questionnaire saying that i need to qualify for the surgery. my BMI is 42, but i dont have any of their listed obesity related issued. Hopefully I will qualify. I will call the office Friday if I dont hear back from them and set up an appointment.

I have several personal/financial questions about your experience, do not feel obligated to answer them, but this is consuming my brain.
 
- Does he or the BCBS of IL require a "supervised" diet? If so, how long was it?
- Did you get approved on the first try with BCBS?
- After all the paperwork was completed/approved, how long did you have to wait for your surgery date?
- Do you know how much a DS revision would be? I have to pay my deductible then pay 10%...just wondering if it was like 30k...

Thanks so much for getting back to me. i am a bit lost and wanting information.
joanne

I don't mind answering any questions for you.  Just remember that everyone's situation is different.  Also remember that I ended up not getting the DS, but a re-built RNY.

1.  "Supervised Diet" - No, I was not required to participate in a supervised diet.  I was required to keep a food journal, I was required to meet with the nutritionists (they are awesome) and the psycologist from his group (also very nice) three times, several months apart, prior to being accepted into the program.  (We also had to find out why I was unable to lose any additional weight because I was physically hungry all the time - which was an Upper GI (I think) proving that my pouch and stoma were stretched.)

2.  Yes, the surgery was approved the first time - I think because of the stretching of the pouch and stoma.  It REALLY surprised me.

3.  I had my final visit (#3) in June, 2008, but the letter wasn't sent to the insurance company until January, 2009 - the office is somewhat slow (though really, really nice), and I had to reach a point where I was bugging them to get any action.

4.  I don't know how much the DS cost.  I didn't ask, because I thought I was going to be self pay for either a band over the RNY ($10K) or the Rose Procedure (also quoted at around $10K) and had the money for that.  My share (after deductable) is going to be 20%.

Answer the questionairre and make an appointment.  Don't give up hope.