How to get BCBS IL PPO to pay for DS if my BMI <50

[hilary1617]

@irishmom1972 RE: #4 above VSG is an integral part of the DS. If you rule out VSG, you rule out DS. If you have reflux challenges you definitely need to discuss best options with Dr. Prachand.

 

[Larra]

@hilary1617 you're right, except that with the DS a more generous sleeve can be made, while with the VSG as a stand alone, if you make a wider sleeve there is much more chance of weight regain. So not all sleeves are created equal, and her reflux can be taken into account with a DS.

 

[DSRIGGS]

@hilary1617 you're right, except that with the DS a more generous sleeve can be made, while with the VSG as a stand alone, if you make a wider sleeve there is much more chance of weight regain. So not all sleeves are created equal, and her reflux can be taken into account with a DS.

@hilary1617 you're right, except that with the DS a more generous sleeve can be made, while with the VSG as a stand alone, if you make a wider sleeve there is much more chance of weight regain. So not all sleeves are created equal, and her reflux can be taken into account with a DS.

I had Barrett's esophagus so Marshall tried to dissuade me from the DS and I told him now way. He eventually relented and I told him if he feared the geometry of the sleeve would produced more GERD to make it wider at the top. I am not sure if he did but my GERD is no worse now than before the DS so I would say it had no impact on GERD.

 

[southernlady]

I had GERD pre-op and I still have it. BUT I had other issues that said I NEEDED the DS...like my diabetes, my NSAID requirement.

Each person has to decide which "evils" you can live with and which you don't. My GERD was an evil I decided I could live with.

 

[irishmom1972]

Hello. So the EOC is not on BCBS IL website when I sign in. I called BCBS again and they've never heard of an EOC. I called Dr. Kane's office in Hoffman Estates to discuss DS today and inquired if the insurance required 50 BMI and if they've been successful getting around that requirement. The insurance coordinator at Dr. Kane's office put me on hold while she read the "Medical Policy" for DS for BCBS IL, and she came back on and said that "Yes, you need a BMI of 50." She went on to say that no cormorbidity was going to help my case because they clearly say that "DS is not medically necessary for patients with a BMI under 50." The coordinator said it must be a new policy because she knows of one patient recently that had BCBS IL who had a BMI under 50 that got denied for surgery. They appealed, denied again. She said last year, she recalls working on a patient whose BMI was under 50 with no comorbities, and the person was denied. They then send in supporting documentation of how this patient had a BMI of 50 at some given point when he first saw Dr. Kane, and they re-submitted that information to Blue Cross, and they approved it. I told her that if they can't help me fight insurance that maybe I should start searching elsewhere for a surgeon. She said that Dr. Kane would probably be in support of my DS decision (instead of gastric bypass that he was recommending). I have another consultation with Dr. Kane to discuss DS. I heard from a member of a FB WLS group that Dr. Kane and associates have done about 60-70 total DS's thus far. Not sure if I should be looking a surgeon with more experience. I've researched high and low on the weight loss boards about various surgeons and read through a lot of recent posts, and those surgeons within 150 miles from me (I'm in Chicagoland) don't do DS surgeries on patients under BMI of 50. Even Dr. Prachand at U of C and Dr. Marshall in Peoria .... who are both within 100 miles of me. I'm wondering if I'm chasing something that I will never get approved. I can't travel to CA or FL or NY because I have six young children and no family that would be able to stay at me while I travel for a few days. Husband can't take off work except for the surgery.

Dr. Kane's insurance coordinator said that if insurance denied me DS, we'd appeal and do a "Peer to Peer" review and speak with the Medical Director at Blue Cross and list all the reasons why DS is the preferred surgery for me. She said even those "peer to Peer" reviews come back denied because they'll say that it's "right in their medical policy that DS surgery is not medically necessary for patients under 50." I'm so close with a BMI of 47, no metabolism. At one point , I was probably a BMI of 48-49 (highest weight that I've seen on the scale is 309). They schedule a sleep study to demonstrate sleep apnea, a comorbidity, but she said that will probably not even help. Any advice here?

 

[southernlady]

@irishmom1972 is your insurance thru an employer? If so, contact the HR department and ASK for a copy of your EOC. They are required to give it to you or give you a link to download YOUR copy.

Do not give up.

 

[Larra]

Whoever at BCBS told you they have never heard of an EOC is an idiot. This is why I'm constantly repeating myself about documenting any and all contacts with your insurer. This would also be a time to request (insist) on speaking with that individual's supervisor. then keep going up the food chain til you get someone who knows that every policy has an EOC, which is essentially your contract with the insurer.
Try working through your employer, but keep after BCBS also. You are entitled to see what your coverage is for yourself. It may not be what you want, but you at least should be able to verify this for yourself. This will also document what, if any, appeals rights you have, which may prove to be very important.

And not to get completely off topic, but I've never heard of a Dr. Kane anywhere doing the DS. If he's doing it, that's something other people might find useful. So, if you can provide contact info for his office (preferably email address) so we can add him to the DS surgeon list we are trying to put together, that would be much appreciated. Thanks!