Research doesn't lie- research, then decide for yourself!

Are you trying to go to Dr. Keshishian too?  I called insurance today and Doctor's office.  Dr. Keshisian is on the BCBS PPO plan, but not the facility he performs the surgery in.  I have the Bariatric Clause and the facility has to be a Center of Excellence.   Diana at his office told me that the Delano Regional Center is only a COE for Medicare.  She said it depended more on my plan the the insurance though.  I was still confused.  Now I sent paperwork today to Dr. Rabkin in San Francisco.  Dr. K's office mentioned him too.  Alvarado Hospital in San Diego only seems to be doing revisions to lap band over band and stomaphyx.  I had heard at first that the stomaphyx was good, but very few insurance plans were covering it.  Yes, I have the hypoglycemia and get the shakes, sweats, dizzy, incoherent, and feel like I'm going to pass out.  I get so desperate for a quick fix that I grab for the bad stuff, or anything, then later follow up with protein. I am getting tested for hyperglycemia tomorrow. The thing is, I think it is related to the surgery and not a true diabetic or hypoglycemic. - but a dumping syndrome)

I'm pretty sure I can get a letter of medical necessity, now that I am up to a BMI of 54 and have some comorbidities (arthritis, asthma, stress incontinence, etc.)


Thanks so much Joyce, looking forward to your reply

Hey friend,
My understanding is that "reactive hypoglycemia" is common with many post-ops.  Best thing....make sure you always pair a protein with a carb to keep your sugars from spiking and diving.

I don't think I have the same issues with the hospital and my BCBS PPO since I'm not really going with the weight loss surgery "clause" which requires a coe.  Mine will be approved as "medically necessary"  IF it's approved!

I've heard nothing but good about Dr. Rabkin!  Let me know how your testing goes and how it goes with Dr. Rabkin's office!  I'll be sending happy thoughts your way for all to work out!!!

Take care!!!

I would think I could go with medical necessity too. I have a BMI of 54, a few co-morbities.  They could do an endoscopy and probably find that my stoma and pouch is stretched and I may even have an ulcer, since my ortho doct who gives me cortizone for my arthritis in the knees (due to being overweight) had me on 800 mg of Ibruprofin.

I just can't even get into the door there.  I just sent an email.  Maybe I need another strategy.
This is for Dr. Keshishian. I thought I would try that again.

I'll here back from Dr. Rabkin's office on Monday. However, they still want $300 for consult and 10k upfront.  I really need to know how much my ins is est. to reimburse though.
Thank  you Joyce

Pam

 Hi

I too have the hypoglycemia and get the shakes, sweats, dizzy, incoherent, feel like I'm going to
pass out.  If I keep my protien up to 80 -100 grams the spell come fewer and fewer.  As far as
Alvarado Hospital in San Diego, been there, not the way to go. The DS is the best for long
term weight loss.

Terry 54

Is BC still playing this game?  I think you can fight it. 

First, I had them send me a list of ALL of their COEs in California--or maybe just in my half of the state--I don't remember.  Then I wrote--email, so I could have it all if writing as much as possible--every one of those hospitals for a list of their bariatric surgeons.  Then I contacted each of those surgeons and discovered that --surprise, surprise--none of the surgeons at the COEs were DS surgeons.

That constitutes what I THINK--I'm not a lawyer--is called "constructive denial" of that procedure.  I wrote to one of their big shots at the time, who said that if my BC surgeons' said I needed a procedure that was covered on my policy then they would cover it even if it meant travel,  (I didn't really want travel, I wanted Keshishian.)   Eventually, I argued with them, they approved it, I had surgery, they denied it, I went back to the big shot's office and they reversed the decision that day.  
So, you can win, but it may take a little time.


So, here's what I would do at this point:

1--collect and assemble the data.  Where are the approved COEs?  Who are the in-network DS surgeons?  where do they practice?

2--get the wording from your contract...make sure you meet all the criteria for the revision and DS.  (You don't want to give them the chance to deny you for a reason that is listed in the contract.)

3--go to Keshishian if that's who you want and have them submit.  (Warn them that there will likely be a denial but you are prepared to work around it.)

4--get a copy of the denial.  (They'll mail you one...eventually.)

5--I would not bother with BC customer service or with the grievance procedure except as necessary to protect my legal rights...those people have no power.  

6--in my case, our insurance is paid for by my husband's former employer (he's retired) by contracted for through my husband's union.  So I'd contact the union.  I find the person who actually is in charge of selecting that contract and--to Blue Cross--is VERY important.  I say something like, "The policy you negotiated for us says--in effect--that we can have a filet mignon or a hamburger...but BC is saying that I must make that purchase at Burger King.  In other words, they have found a way to deny the benefit you negotiated for us.  I suppose the only reasonable solution is that they pay for my travel and the travel of a family member and hotel and all that so that we can go to a COE somewhere else...but that seems like it would be MUCH more expensive.  Can you help me untangle this web?"

7--I don't know for sure how the State Dept of Insurance figures in here, so I'll mention this thread to an expert or two.



Good luck,

Sue

Sue,
Thanks for your detailed guidance!  My case is less about a COE and more about proving I am in need of a lifesaving surgery (medically necessary)  but I definitely will go straight to your steps 5, 6 and 7 since I already submitted their required grievance step (with a letter attached from Dr. K)

I sincerely wish P Gomez luck as well!

Kudos for paying forward your own successful battle strategy! 

Now, the gastric sleeve sounds sort of similar to the ds, can anyone enlighten me on this?  I haven't started any research on it yet.

You are correct. The stomach of the DS is the same as the sleeve. The DS then adds bypass for mal-absorption.

I need help.  I had roux-n y in 2006. My weight was 306.  I was down to 185 now I'm at 210.  I'm starting to get depressed.  My goal was 165.  I don't know what to do.  Please, i neee help!!!

Basically, Sue is right about how to proceed.  I find it difficult to believe that Keshishian is operating out of a non-BCBS CoE facility, given how many Californians are with BCBS.  So first, check with his office and see what he has to say about it.

If you have to appeal, I would try hard to get BCBS to buy Sue's "filet mignon vs. hamburger" argument.  The reason is, I don't know if the DMHC has the authority to overrule the contractual requirement that the surgery should be done in a CoE.

If that fails, you could still take the fight to the DMHC, or you could argue that BCBS has to pay in-network reimbursement rates for you to travel to see Rabkin, who DOES have privileges at BCBS CoEs.  Given Keshishian's upfront and non-insurance reimbursable program fees, the difference in cost could be negligible.