irishmom1972
Member
- Joined
- Sep 21, 2015
- Messages
- 21
Hello. Thanks everyone again for your suggestions about getting BCBS IL to pay for DS. I had no luck with getting the EOC (explanation of coverage). I called BCBS and they read the Medical Documents to me. My surgeon's office read the medical documents off of BCBS's website, and everything clearly says,
Duodenal Switch Surgery is NOT considered medically necessary for patient with BMI's under 50.
My husband and I have had a rocky marriage for years. He carries the insurance and is really being no help to me about asking his HR department to retreive a EOC document for Weight Loss Surgery. My husband could care less if I get the surgery or not. I just had a sleep study and have been diagnosed with obsturctive sleep apnea. I have migraines, fibromyalgia, low back pain and knee pain too. According to many people I've talked to including a member on a FB WLS board who works at BCBS IL in the claims department said that BCBS will deny, deny, deny because my BMI is under 50. Is this a fruitless effort? My BMI is 47 right now. I'm only 20lbs or so away from a BMI of 50!! I'm so close, but I know BCBS will be black and white when approving/denying it. At my heighest I could have been a 50 BMI but it was never officially documented. There's a ton of cancer, diabetes, heart disease, and high blood pressure in my family too. None of my own cormidities seem like they'll help my case, nor will my family history.
I'll still try to fight this with insurance, but there's a risk that WLS won't even be covered next year, so I feel like I'm running out of time. With six young children on one income and with a husband who's not supportive, i can't go fly to Mexico and pay out of pocket...don't have money or a trustworthy caretaker for my children while I'm recovering, etc.
Any suggestions? I think the key is to prove to BCBS that DS is medically necessary for me, but I don't know how. They'll just tell me to go get bypass or something, which is covered.
My surgeon is on board and he says that it's not up to the insurance company to determine what type of surgery I need, but I know that's all talk. If I can't pay out of pocket and can't go to Mexico to even have an affordable surgery out of pocket, I don't have the time or a sitter for my kids. So the insurance will try to drive this decision. Any help here? My surgeon does way more gastric bypasses (the Kane Center in Hoffman Estates, IL). I have an appt. with the University of Chicago team this week to discuss DS, but they told me up front that they typically reserve DS surgeries for BMIs over 50 or if it's under BMI ...for those with severe diabetes. I know U of C is a a great hospital to get DS surgery but I wonder if it's a waste of time for me to even go to them if they told me up front that they typically don't do DS surgeries on my type of patient profile. I wonder if my history of multiple rounds of IVF and feeling like my hormones & metabolism are all screwed up would help me with my case...to prove that DS surgery is medically necessary for me.
Duodenal Switch Surgery is NOT considered medically necessary for patient with BMI's under 50.
My husband and I have had a rocky marriage for years. He carries the insurance and is really being no help to me about asking his HR department to retreive a EOC document for Weight Loss Surgery. My husband could care less if I get the surgery or not. I just had a sleep study and have been diagnosed with obsturctive sleep apnea. I have migraines, fibromyalgia, low back pain and knee pain too. According to many people I've talked to including a member on a FB WLS board who works at BCBS IL in the claims department said that BCBS will deny, deny, deny because my BMI is under 50. Is this a fruitless effort? My BMI is 47 right now. I'm only 20lbs or so away from a BMI of 50!! I'm so close, but I know BCBS will be black and white when approving/denying it. At my heighest I could have been a 50 BMI but it was never officially documented. There's a ton of cancer, diabetes, heart disease, and high blood pressure in my family too. None of my own cormidities seem like they'll help my case, nor will my family history.
I'll still try to fight this with insurance, but there's a risk that WLS won't even be covered next year, so I feel like I'm running out of time. With six young children on one income and with a husband who's not supportive, i can't go fly to Mexico and pay out of pocket...don't have money or a trustworthy caretaker for my children while I'm recovering, etc.
Any suggestions? I think the key is to prove to BCBS that DS is medically necessary for me, but I don't know how. They'll just tell me to go get bypass or something, which is covered.
My surgeon is on board and he says that it's not up to the insurance company to determine what type of surgery I need, but I know that's all talk. If I can't pay out of pocket and can't go to Mexico to even have an affordable surgery out of pocket, I don't have the time or a sitter for my kids. So the insurance will try to drive this decision. Any help here? My surgeon does way more gastric bypasses (the Kane Center in Hoffman Estates, IL). I have an appt. with the University of Chicago team this week to discuss DS, but they told me up front that they typically reserve DS surgeries for BMIs over 50 or if it's under BMI ...for those with severe diabetes. I know U of C is a a great hospital to get DS surgery but I wonder if it's a waste of time for me to even go to them if they told me up front that they typically don't do DS surgeries on my type of patient profile. I wonder if my history of multiple rounds of IVF and feeling like my hormones & metabolism are all screwed up would help me with my case...to prove that DS surgery is medically necessary for me.