Question:
Has anyone who had a DS & Blue Cross/Blue Shield Federal Benefit Plan refuse to pay?

   — Sheila K. (posted on January 9, 2003)


January 9, 2003
This is something I am afraid of also. But, my surgeons don't proceed until they have the approval in writing. Most all of the docs I've read about will help you set up a payment plan if it turns out you have to pay the bill. This is the very least your surgeon can do for you since he kind of jumped the gun by not getting you officially approved first. Good luck
   — Delores S.

January 9, 2003
I am more than a little surprised that a Dr. would do the surgery without a letter of approval form the insurer. My Dr. would not even scheduke me with out the letter of approval, that it was a covered benefit.
   — **willow**

January 9, 2003
also as an RN, the first lesson was never assume... break down the word into 3 parts and you get ass/u/me. every medical Dr. knows this. It makes me mad that you might get stuck with an enormous bill because some one didn't follow up properly in advance. Most hospitals also check out the insurance in advance for planned admissions too.
   — **willow**

January 9, 2003
Unfortunately I am a little afraid your appeal will not be successful. I say this because I just got my approval letter the other day and it said that they would only cover a standard RNY gastric bypass and vertical banded gastoplasty. It indicated that a mini or long limb RNY would not be covered as being experimental. I never thought to ask if DS was covered as I did not assume they would come back and tell the doctor how to do their job. I planned to have the RNY anyway, but was very glad at that point that I didn't have my heart set on DS. However, I still technically have a problem in that my surgeon wants to do a 150cm bypass on me because of my BMI but the procedure code indicates it's for 100cm or less. So I don't know how this will all turn out. I'm 99% sure that BCBS uses the same medical criteria nation wide, so I am guessing the same restrictions are on your policy.<p>I'm with the others in that it's hard to believe the doctor's office would do things by phone and not get it followed up in writing before surgery. My doctor won't give you a date till you either agree to self-pay or have a written insurance approval. My surgeon does have a special package price for self-pay patients that includes special pricing agreements with the various doctor's and the hospital involved, which I am assuming is considerably less than what my total will be with insurance. So worst case scenario I would ask for your surgeon's self-pay price so that if you end up paying it should be less.<p>My biggest complaint even with the RNY restriction in my letter is that the insurance company is behind the times. Surgeon's have been doing 150cm bypasses for a while now and especially on super morbidly obese people as they need the additional malabsorption for long term success. The insurance company is trying to lump all morbidly obese people into one category and there clearly is a difference in the needs of the SMO. Good Luck!
   — zoedogcbr

January 9, 2003
Federal Blue Cross/Blue Shield does not preapprove anyone for anything. Their criteria is that you weigh over 100 pounds which you did. The problem is in their booklet it says what they pay for and that is gastric bypass or gastric stapling. It doesn't say it pays for every kind of weight loss surgery and it doesn't say it pays for DS. Their lack of preapproval is burdensome especially when it comes to plastic surgery, but it is a good insurance. I would keep appealing and if I had to I would go to OPM, but (and I hate to sound negative) it is not something that they pay for. Believe me when I say I wish you the best of luck in this.
   — Lisa N M.

January 12, 2003
On the good side, they can't repossess your new anatomy, right? :-) Hope it all works out -- good luck!
   — mmagruder




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