Blue Cross Blue Shield of Texas

I have BCBS of TX TRS Active Care 2.

My cousin also has the same insurance, same level. She had surgery in Feb. She said that it paid all but 10%. She did the whole medically supervised diet, had diabetes, etc.

Right now I'm waiting on approval. There was a screw up at my doctors office and it wasn't submitted when it was "supposed" to be. It was "re"submitted 5/23, origionally it was "submitted" 5/15. I'm frustrated with them.

 

On May 26, 2008 at 6:46 PM Pacific Time, Chivas L. wrote:

I have BCBS of TX TRS Active Care 2.

My cousin also has the same insurance, same level. She had surgery in Feb. She said that it paid all but 10%. She did the whole medically supervised diet, had diabetes, etc.

Right now I'm waiting on approval. There was a screw up at my doctors office and it wasn't submitted when it was "supposed" to be. It was "re"submitted 5/23, origionally it was "submitted" 5/15. I'm frustrated with them.

 

I know how you feel - believe me!  My doctor's staff took 3 weeks to fax the paperwork over to BCBS.  I was so aggravated... grrrr.......  I know they are busy, but come on - 3 weeks? I waited a week and then I called BCBS to make SURE they had my paperwork and I almost dropped the phone when the lady said I had been approved.  I must have sounded like an idiot with a comprehension problem.  I kept saying "Really ??  Are you SURE"  "I have actually been A-P-P-R-O-V-E-D"?" I hope you hear something soon!

Shanna,  It all depends on what your employer has in their clause. I work for the state and have BCBS of TX PPO. THey denied my Lap Band request and denied the appeal, but after I met teh 6 month doctor visits, over 40 BMI, documetation, etc. I was approved and had surgery in less than two weeks. My husband was denied by his insurance and approved under mine in less than three weeks.  Don't give up. Look at he link that Paul gave you. Call the number on your card and ask if they cover WLS. Be specific, say lapband, DS, RNY, etc. If they say yes, ask what the criteria for coverage is. Good Luck! Gina

I am fustrated with them. :-(
First they said it was covered and I went though the six monthly visits routine.
Now they say it isn't.
That put off my hernia surgery six months.
Now it can't wait, it should have been done months ago.
Maybe they will change their mind on the band after I recover from the hernia surgery..

I have not tried anything lately but I need to back to work on it.  What really bothers me is the BCBS says my employer put the clause in the policy for no WLS.  I have talked to my employer and they did not put it there.  So that tells me BCBS puts it in the policy and lies to the policy holder knowing they probably wont go any further with it.  I think its time to start over again and really put up a fight.  Maybe get a lawyer to help.

Shanna

I apologize as I know that this is an old thread and I seem to be jumping on the band wagon a little late, but to those of you that have been able to get Blue Cross Blue Shield of TX PPO to pay, "you are my heroes".  I want to be you when I grow up! I have insurance that the State of Texas sponsors for people that are considered so high risk that they are uninsurable (see link below for those interested - there are pools in most other states as well).  

http://www.txhealthpool.com/

My dilemma is that BCBS's "Outline of Coverage" states that it won't cover treatment of obesity as detailed below.  I have read all five plans and for those of you that may like to read the nitty-gritty, here it is in black in white:

- Bariatric surgical procedures or complications related to such surgeries, even if the Insured Person has other health conditions that are related to, caused by or impacted by excess weight, obesity or morbid obesity, or any program, product or medical treatment for weight reduction or any expenses of any kind to treat obesity, weight control or reduction. AND
- Appetite suppressants or any other drugs prescribed for weight loss.

My cir****tances are these:
- I have severe osteoporosis, so I have broken 28+ bones in the last two years.  I have multiple fractures in my back with six back surgeries, one after the other, that managed to catapult me from my all time high of 220 to 333 over a period of about a year.  It is amazing what laying flat on your back while eating the same way without exercise will do.  
- Due to the osteoporosis, I have shrunk four inches and thanks to some good drugs, I regained an inch.  This has done some wacky things to my BMI, but it was 67 at it's highest and is currently 53.  I have lost over sixty pounds since last July which helps, but I am still super fluffy. 
- Symptoms of Type 2 Diabetes, but I don't carry the diagnosis 
- Two TIA's (mini-strokes)
- Multiple deep vein thrombosis which are known as DVT's or quite simply, blood clots.  Two have landed in my lungs almost killing me, so I have major inflammatory /vascular /vasculitis /phlebitis issues.
- High cholesterol
- Asthma
- Sleep apnea
- Arthritis, but I am lucky enough to have the non-destructive kind
- GERD
- Skin infections
- Infertility issues and related gyn problems out the yin-yang from premature ovarian failure (early menopause) to no libido and
- I am on oxygen 24/7.  My doctors believe that I am oxygen dependent for several reasons: 1) I've never really been a good, deep breather; 2) Pain and medication that I am taking suppress my breathing; 3) It's more difficult to breath when there excess weight pushing against your lungs; 4) When I shrunk, it compressed my lungs

It seems like from my back, broken hips, and osteoporosis there should be enough ammo to get them to pay for my surgery; however, I went to the WLS seminar for Dr. Nicholson (who is the only surgeon my specialists will allow me to use and really the only one I feel comfortable with), filled out all of the paperwork, and they won't even let me make an in office appointment with him because my insurance has denied everything.  They have said that I need to pursue this fight against them, but how can I do that without a doctor at the helm?  Don't get me wrong, Dr. Nick is NOT the "bad guy" in any of this since I see doctors as just as much of the victims these days as we are, but I am a little frustrated because I am getting the same type of response from my endocrinologist, pulmonologist, rheumatologist, hematologist, and internist who all really want me to have this done.  They are saying that due to my insurance's "Outline of Coverage" it's futile.

Where do I go from here?  I have always been able to lose weight before, but I was more active then and I always gained it back within five years.  From July to December, I lost sixty pounds and just hit a wall, so now I am hitting it hard again....  I have taken WLS prescription meds in the past as well too, but those aren't an option for me.

So, now that you know where I have been, where I am, and what I would like to accomplish.  I am so sorry this is so long, but believe me it is the Reader's Digest version. 

Thanks for sticking with me.

Sincerely,
Shelby

Hi Shelby,

I too have had BCBS of TX. I finally got someone at BCBS to tell me the truth.  What they are telling all the folks covered by them is that the employer is putting the clause in the policy but it is  BCBS is putting the clause in the policy.  So BCBS puts it in the policy, tells the employee that the employer has put the clause in the policy so everyone gives up on trying to pursue it any further and BCBS (as well as other ins. companies) are getting away with it.

I was told by BCBS that when an employer is shopping for insurance for its employees they just pick the policy that is right for them such as deductibles, prescriptions, copays, cost, etc.  Kind of an off the shelf type of purchase. The employer doesn't know that this particular exclusion is in the policy and BCBS (and others) are getting out paying for WLS.  Some of the BCBS policies in other states will pay for WLS but not good ole BSBS of TEXAS.

I have been switched to United Healhcare and it is the same problem.  They just picked out the same type of policy.  I know this is not right and I wish I knew how to fight it.  I am also afraid to push to hard for fear of the insurance doing something against the company I work for such as dropping us, raising the rates sky high, etc.

My daughter had the RNY last Oct. (and is looking great!).  She is covered from her job and her husband covers them too at his job.  BOTH policies covered her surgery!!!!  Neither one batted an eye about coverage.  I know there are insurance companies that are getting it and realize how many complications will improve or go away with the WLS but the others are just looking at their bottom line (and are getting away with it).  So I am just as frustrated & angry about this as you.

I have worked on this for several years, had my drs. write letters been to Dr. Warnock in Wichita Falls & another Dr here in Amarillo, been to 2 or 3 seminars, read all the WL books, have all the health issues, am willing to go thru the 6 month program that the new dr here in Amarillo requires before surgery but I can't even get an consult appt with him because ins. wont pay for even an office call on bariatrics.  PERIOD!!  Of course I can see him if I want to pay cash but why pay  $200+ office call when I can't get the surgery.  The only other way is cash and I don't have $25,000+ in my back pocket.

I am so ready for WLS and so frustrated!!  I know this doesn't help solve our problems but it is sure nice to vent to someone who understands.  Hope I didn't ramble on too much.

Shanna

Thank you Shanna! 

I'm sorry to hear about all of the problems that you have had with your insurance company.  It's hard to know where to begin when both parties are pointing fingers at each other - especially when you are in my scenario, you only have one option for insurance, and/or you can't exactly call the State of Texas to complain about the limitation placed upon the plan they have been gracious enough to supplement with grant money from our taxpayers dollars foods so people like my husband and I will have insurance.  It seems like from a sheer economic perspective they would begin to have caught on by now.  

I noticed that you aren't that far from me.  I wanted to pass on some information about the doctor that I would like to do my surgery, Dr. Nick Nicholson.  One of the things he offers, other than cash pay, is a payment plan since they understand that a lot of people are making payments for their surgeries.  They have catered to this niche of the market by working with the Baylor Healthcare System to set prices for the RNY, Lap-Band, and Sleeve ranging from $12,000-$17,000. The nice thing about this option is that there is an exact price without absolutely any financial surprises which we can't always say about insurance when it does cover the surgery.  I have attached a link for him in the event that you are interested.

http://www.nicholsonclinic.com/payment/

It must be the policy u have cause I have BCBS of TX and it is covering my revision from lapband to Bypass...I paid for my BAND and they r paying for my BYPASS....Good luck

I am a teacher and I have BCBS Active Care 2. It covers WLS as long as they are done at a Blue Distinction Center with 3 month medically supervised diet. All versions of BCBS are not the same and it appears that your coverage is dependent on the policy your employer picked.  Apparently the plan choosen for Texas teachers does cover weight loss surgery.