Question:
Denied becasuse BC/BS considers Investigational

I want the DS and I called the RN who denied me and asked why. She said it is because they consider the surgery investigational. She advised that I would get approved for a different procedure, but that is not what I want. Do I fight it or do I settle for a different procedure? Did anybody get approved for a DS with BlueCross BlueShield of California PPO. Please help me.    — davesband1 (posted on January 13, 2003)

January 13, 2003
I was speaking to someone at the doctor's office today. They have had the procedure done 10 weeks ago. They said the doctor's office has to use a different code as the primary, for instance, if you have hypertension, or high cholesterol. Hope this helps.
   — choudoun

January 13, 2003
I had the Ds done and BC/BS paid for it because I had a precancerous condition in my stomach that ruled out the RNY. Although my surgeon sent a letter to BC/BS for this they initially denied and I had to keep at them for awhile. In the mean time I found another surgeon on the other side of the state that does the ds but codes it the same as the RNY. The difference is in the length of the common channel. I am happy with the DS but I find that because I can eat whatever I want and I love those refined carbs that I have slowed in my weight loss and do wish that I had that internal feedback machine that told me immediately to stop eating sweets.
   — kathleen S.

January 15, 2003
Okay. First let me say that I went all ten rounds with BC/BS CA PPO. I wanted the Lap Band. They considered it investigational. They gave me a list of approved surgeries. This went on for a YEAR. They never did approve the Lap Band. When they say it is investigational, they really are saying that they will not put the procedure on the approved list until there are X number of studies done showing the long term results. The studies have to satisfy BC/BS. Every WLS case is put before a doc. The doc that reviewed my case was a podiatrist. When my surgeon called, and asked what the heck was goin on, he was infuriated to discover that the only way they will pay for RNY is if you bypass less than 100 cm. He told the doc at my ins co, that it wasn't exactly measured, just kind of guess-timated. They went round and round, and I finally got approved. If what you want is considered investigational by their standards, I would try to choose another surgery. Otherwise, you could be waiting for a LONG TIME. SORRY if this is not what you wanted to hear. Feel free to contact me if you have any questions....Love from Texas, Ann
   — Ann H.

January 16, 2003
Something like that happened to me too with BCBS of TN. I got the open RNY and I have been very happy with it. not quite 4 months - down 81 pounds! Good luck either way.
   — Pam G.