Question:
has anyone had any recent experance with bc/ bs of michigan ppo

I know bc has changed their guidelines for qualifing, for them to cover the wls surgery. Has anyone had an experience with them in recent months. Any help would be greatly appericated. I was told I didn't have enough commorbities yet. I am just shy of 300# and I'm just about 41 yrs. old. They said that if I didnt have high blood pressure, or diabeties so I dont qualify. ( This was hurley comprenensive weightloss center that told me this.)All of the Major commorbities run in my family I may not have them Yet but if something doesnt change I will. Can anyone help?    — Toni R (posted on July 6, 2003)

July 6, 2003
I have BCBS of Michigan,I haven't been approved on paper yet but I've talked to them several times.I was told if my BMI was over 40,I was more than 100 pounds overweight, between the ages of 18 and 62,I would be approved.I meet all these requirements.My surgeon sent the paperwork in last week so now I'm playing the waiting game!
   — Gussie

July 6, 2003
Hi, wow is this a sore topic for me!! I hate to tell you but your not going to get approval on paper! They (ins) don't require any PRE approval/cert or anything. Please read my profile for more info. I had to self pay and then the paperwork gets submitted to ins for approval, as long as I meet the guidelines then I should get my money back. $16,000.00 in all. Good luck!
   — luckyflowers

July 7, 2003
I have BCBS/PPO Michigan and I had no problem at all getting approved for open rny at btc. I have very mild sleep apnea, irregular high blood pressure, arthritis, tired all the time and many failed diets. That's all the Doctor and I had to say and I got approved the 1st time. Now btc does not even except bcbs and im having a hard time getting them to pay for my post-op lab work that they are suppose to cover 100%. 2 viles of blood taken and they sent me a bill for $300.00....YA RIGHT! I told them they wont get a dime from me and now I cant get any blood work done, so who knows whats going on with me. They now are saying it will be corrected and so far...nothing! Now I get to fight for a TT. Good luck to you:o)
   — Sandy M.

July 7, 2003
I have MI BC/BS PPO and had no problems. The only requirements I had was to be over 18, BMI of 40+, and a co-morbidity, and had previous weight loss attempts. I was 261, 24, hypertension-- and got approved right away through Dr. Wood, Warren, MI.
   — Angela G.

July 7, 2003
I have bcbs of michigan ppo. Being from out of state the main problem I had with them was getting through to the appropriate person who knew what they were talking about. Did you speak to an account rep or someone who specializes in pre-authorization? Sometimes the account reps are not familiar with procedure. Once I got through to the proper person I was told that there is no pre-authorization required for the gastric bypass surgery. She told me if my bmi was 35(with co-morbs) or 40 or above no co-morbs all I had to do was get a psych eval, pass pre-operative bloodwork and have been overweight over 5 years with attempted supervised diets (although they didn't require proof of diets). Once the Surgeons office submits ALL this paperwork you will receive a letter clearing you for 2 day hospital stay with surgery. It is very important that the surgeons office submit all the required paperwork for approval. I actually switched surgeons partly because Anez has a very efficient staff, they were familiar with bcbs procedures and they sped up the approval process (he was also a more experienced surgeon,and cheaper). Whoever you spoke to was mistaken, you definitely qualify. I weighed 305, 5-5, and had my surgery 2/12/2003 with no delay. Hope this info is useful.
   — Cupcake B.

July 8, 2003
In my opinion you DO meet BCBS requirements however for whatever reason Hurleys must only be willing to perform surgery on you if you have co-morbities to go along with your BMI, probally because they are not confident enough in thier documentation process of submitting for reimbursement after surgery and think they need to be able to put some co-morbities along with your BMI. I personally went through BTC 1 year ago with BCBS and only had a BMI of 40 and a co-morb of asthma (which had nothing to do with weight, but with allergies) and was approved with no problem. The Co-Morbity becomes a BIG factor if you have a BMI of less than 40, so if you only have a BMI of 35 you DO have to have co-morbities to associate with the lower BMI. It would be in your best interest to contact a different surgeon, your not that far from Grand Rapids, MI. MMPC accepts the PPO and you can have it done LAP instead of Open. There are also places in Warren and so forth. If Hurleys doesn't want to do the most they can for you than go somewhere where they will! Good Luck, Becky
   — Rebecca B.

July 8, 2003
I have BC/BS MI and had my surgery(open RNY conversion)3/28/03 and it was covered. My doctor's office handled everything. My doctor is Dr. James Sapala, in Jackson MI and the surgery was done at Harper Hospital in Detroit and they were all great! Maybe you should ask a different doctor's opinion. I didn't have high blood pressure or diabeties and I was your weight pre-op, but I was 55. I still think it's worth a another opinion.
   — Linda K.