BCBS of TX

Ok soo I had lapband in2008 paid CASH for it now I need a revison due to No weight loss and I have gain some weight My WLS dr submitted my paperwork last Wed. and I found out today I was DENIED....BCBS of Tx said since I had surgery back in 2008 I  need to meet there requirements as far as a 5 yr documation of being Morbidy Obese....Well For  1 I didnt have this insurance in 2008 just got them in 2009 for 2 I self paid and for 3 the policy has been updated on 7/1/09 and you dont have to have a 5 yr history anymore so WHY DO I HAVE TO GO BACK 2 YRS AND FOLLOW THE OLD POLICY????????? IF ANYONE HAS ANSWERS PLEASE GIVE ME SOME......I HAVE TO CALL THE DR'S OFFICE TOM SO THE DR CAN CALL AND MAYBE HE CAN DO SOMETHING....OTHER THAN THAT I WILL APPEAL APPEAL APPEAL...............THANKS SHANNON

My experience is that you need to appeal right away.  Outline the basics like you just did in your post but take the "edge" out of it.  Keep it to facts ...like listing the course of events and how it has effected your healthy, emotionally, physically....  Have your surgeon and a few dozen close friends or family members look it over.  Ask your surgeon to write his own appeal letter and include that with yours then send. 

The haggling over the phone is pretty much useless since the hourly employeess don't have a clue and it's difficult to ever get through to someone who will make a decision.  The surgeon can't usually initiate a peer to peer review with the insurance docs until the 1st stage appeal has happened.    Having worked in Bariatrics, I know that the 5 year documentation is usually pretty easy for most to get.  They just need copies of their doc records for the 5 years since most of us have had co-morbidities, we have usually gone into the doc at least once or twice a year and they ALWAYS weight you.

Your points are very valid.  Hopefully your insurance company will "get it"!

Good luck!  Be a warrior and win!!!

Ok  so they said I need 5 yr weight docs. from 2005 well I have found 2006-now do you think that will be good enough I'm just missing 2005? Thanks shannon

If you see the Dr. for any reason and you have been weighed  get a copy of the visit with weight on it.. You only need one documentation for each year to show this is an ongoing problem.  If you don't have 2005 use 2004 or earlier. The more comorbidities you have documeted the better, HTN,sleep apnea arthritis diabetes etc.  Good Luck!

 Appeal.

They are asking you to meet the criteria for an INITIAL wls, not for a revision.  You need to find out what the REVISION criteria are.

Surely they cannot reasonably insist that you spend five years being morbidly obese again to qualify for a revision.

Soooo my letter came in today....and this is what it says.....

Unfortunatley we were unableto process the inquiry due to the reasons:
  Need medical records for patient
  We need a History and Physical Report
  5 Yr HISTORY OF MORBID OBESITY, DOCUMENTATION OF ACTIVE PARTICIPATION NONSURGICAL PROGRAM OF WEIGHT REDUCTION ( 6 MONTHS WITH DATES) AND PSYCH EVALUATION PRIOR TO 1ST BARIATRIC PROCEDURE.

They said once they have all of that they will review it once again...Just talked to BCBS and I have the 5 yr weight history and she said I should be able to use my charts from my provious WLS Dr since I was on a High Protein low carb diet ok so that is done now they said since I was SELF PAY the Surgeron just has to write a letter stateing I was self-pay so I was not required to have one done.

If this sounds  about right or if anyone has any advise please let me know......I have the BAND now and I'm trying to get the BYPASS done.... Thanks Shannon

I’m done with all my required pre-op tests. I called my surgeon's office and my GI series test results came out normal according to the secretary. I’m happy about not presenting lap band complications. But I'm concerned because I think that people  with complications after lap band surgery become eligible for insurance cover for revision surgery. However, it is  more difficult to get insurance in cases of revision surgery for unsatisfactory weight loss. Any information would be greatly appreciated! .... 

 

Hi, Shannon, I am dealing with BCBS too... I went to a new WL practice they submitted my info to BCBS for revision from Band to Bypass. They  sent them a similar letter about the 5 yrs medical, phsyc, and 3 months of weight loss program. I knew this was wrong I had to call BCBS myself and they pulled up the letter they sent me the person was in awe "I not sure why we sent that letter to you that is not the new criteria" So anyhow I we went back and forth 3 or 4 phone calls until a supervisor got involed, there is no criteria for revision i was told. I ended up having to change WL drs. to a more expirenced staff, they sent my ppw in work to have band removed that was done on the april 12th.  My ppwrk was sent in on 5/4 for bypass hopefully I'll know something by Wed. Ins. person at DR. office said I should be approved since I have met previous requirents the first time. Keep working on...Good Luck 

Michelle