Question:
has anyone with Blue Cross California HMO been covered for surgery?

I definitely want this surgery. I am a 30 y.o female , 5ft and 257lbs. I have struggled with my weight my whole life and have tried sooooo many diets and programs, always losing a little but not being able to keep it off. I turned 30 in sept and can feel my body not being able to deal with the weight anymore. I have problems sleeping, can barely get up the 12 steps to my front door and am sick and tired of feeling sick and tired. Most people have told me I would have to switch to PPO first but I was wondering if that's necessary. Also my primary care physician keeps telling me to eat right, go to the gym and that I don't need the surgery since I haven't had any kids yet. Anybody have any advice?    — BMI50 (posted on April 25, 2007)

April 25, 2007
First of all -- not having kids doesn't have anything to do with your desire to loose weight. Women who've had the surgery are giving birth to healthy babies AFTER the surgery -- you have to wait 12-18 months but that is because you have to give your body time to heal; lose the weight you want to lose; and replensih your body with the necessary nutrients it takes so that you can feed the baby for 9 months. Second, you don't have to swith from a HMO to a PPO; however, I have found that its less stress going through the process with a PPO because you don't have to deal with referrals. That may be the reason people have told you that and I agree with them. Third, put your foot down on the doctore -- is the doctor willing to support you in obtaining the surgery --just flat out ask the doctor. This is about you and not about the physician. If the doctor is not willing to support you in your decision -- drop him/her like a hot potato. Another reason to probably go ahead and drop this physician -- since you have trouble sleeping -- has a sleep apnea test been conducted on you? I and probably a hundred other people on this board can testify to receiving the same type of response from a doctor at some time in our lives; however, they didn't provide me with any tools to begin the weight loss process. I suggest finding you a female Internal Medicine physician -- that's what I have -- as your primary care physician -- not a general practitioner. On your first visit let her know that you are seriously considering weight loss surgery and would like her support. I believe you would greatly benefit from the surgery. I'm a little over 2 months out with lap RNY -- I'm 46, 5'6' and now weigh 245. Surgery date I was 286. I'd suggest browinsg the links on this site where people have posted their experience with your insurance company in California and go from there. Also check to see which hospitals have a bariatric clinic and make appointments to attend some of their seminars -- no insurance referral needed.
   — the7thdean

April 25, 2007
I agree with the other poster, having kids has NOTHING to do with it. I was 23 when I had the surgery, and now I am 27 have a 6 month old, and I am pregnant again with #2. I also had all the plastic surgeries! So don't let anyone stop you. My life if better now that I am a healthy weight. And it is easier on a small person having kids--I never had to worry about high blood pressure or too much weight gain!
   — GAYLE CARMACK-LYONS

April 25, 2007
Definately time to drop this PCP. He is looking down his nose at you, and he's probably never been obese his entire life, so he has NO idea what obese/morbidly obese people go through! He sounds like he's just in it for the money, and doesn't care about the patients needs. Unfotunately, there are doctors out there that don't treat the obesity, they only treat the co-morbidities. Referrals are not hard to obtain, just make sure you have a PCP that is going to support you in this journey. I did and I don't regret it at all. I'm one month out and am looking forward to the rest of my life! Good luck!
   — crystalsno

April 26, 2007
Hi Varsenik, thanks for writing. You are doing a good thing asking questions and getting yourself the information you need to look realistically at surgery. It is not a small thing. Blue Cross is a pretty good Ins company, but each plan has it's own policy's on wls. You have to contact them directly. I had Tricare prime when I had wls, so I can't help in that area, but really no one else can either. Even if someone has the BC in CA HMO, it might be with a clause to cover wls, and yours may not. You really need to contact them directly. They should speak honestly with you about it. If you need to update to a PPO, I would recommend that because the coverage is so much better. I changed to BCBS PPO when it came time for my Tummy Tuck, and they covered exceptionally well and paid my physician better than my prior plan. I was glad for that, because they worked hard and deserved the pay. Regarding your PCM. If they cannot support you in wls, then you may have problems in follow up care with them as well. You may want to look in your network and see if there is a change you would like to make. A PPO (most of them anyway) does not require a PCM to refer you on. I don't need to see my PCM unless I want to. If I want to see a specialist, I just make an appt with one. I like that coverage. I usually take the advice of my wls surgeon, and I do have a PCM for general care, but use her for just general care. She is also supportive of wls. I have arthritis now in 4 areas, and even though it hurts to have it, it would be 1000 worse with an additional 120 pounds on my body. Now, regarding babies. I am worried about young women who have this surgery and have not completed their desire for childbirth. I really think you are wise to think about this, and give it good honest thought. In a perfect world, surgery would go great, you would lose weight and wait the 2 years, and you and a wonderful husband would bear children and again you would take the weight off. In the real world, sometimes complications are a problem, or women get pregnant too soon, and this can put the baby at risk if they do not get enough nutrition. If you are mal absorbing vitamins and minerals, the baby may not get all they need, especially if you end up with a complication with mal absorbtion. I would not just say "GO FOR IT". Please consider the doctors advice regarding children. They may be completely wrong, and I know it hurt, but give it honest consideration before you move forward. You only get one body, and if you really want children, I know you would never want them at risk right from the womb. That is not worth any amount of weight loss. I am very simpathetic about your weight and your plight. The decision was easy for me in this area because I have my three healthy boys and could not have any more, I knew I was done. I don't know if I could bear a pregnancy after wls. I am sorry I couldn't just say DO IT, but I hope you weigh all the issues before you decide. If you decide to move forward, I would consider changing to a PCM that can handle a wls patient with support and dignity. You pay for it, and deserve that. Take care. Patricia P.
   — Patricia P

April 26, 2007
I am 35 y.o. and had RNY/LAP on 2/15/07. I have not had any kids, to date. Your PCP is crazy. I would switch and get one on your side. With your history, it should be a no brainer. Secondly, I have Pacificare HMO, they covered the surgery as I qualified for all of their criteria, my medical groups and my surgeon's. I would switch PCP's and call your medical group, they can tell you what to ask the insurance company...specifically the medical number assisgned to gastric bypass surgery. I called my insurance company and asked if they covered 4598 (or whatever the number was) and they were able to look it up quickly and I got my immediate answer. I paid nothing out of pocket for the surgery. It might take a bit longer to get approved going the HMO route, but it was worth it to me. Good Luck!
   — jammerz

April 26, 2007
Hi Varsenik, I see that you live in the Los Angeles area. I think you should have no problem with the insurance you have already to get surgery. I had my surgery in December 2006 and I am 34 years old. I have a really nice PCP who had no problem with my having surgery and actually encouraged me to have it. If you need someone to talk to and to get recommendations please don't hesitate to call me or email me at [email protected]. I wish you the best of luck & health in your life. Anita Danelian
   — AnitaD

April 27, 2007
what your dr. is not telling you is that less then 4% of people 100lbs overwieght can loose and acualy keep ther wieght off get a new doc.
   — ughlybeast

April 28, 2007
i went to my pcp on march 28 2007. blue cross hmo approved me april 4th 2007 you have to have your pcp's support
   — aguiniga