Question:
Has BCBS changed there WLS policy?
I was just at the BCBS web site and decided to look at their "news". I found this and I will copy and paste it here. "he MAP concluded that: * laparoscopic gastric bypass with Roux-en-Y anastomosis does not meet the Blue Cross and Blue Shield Association Technology Evaluation Center criteria; * laparoscopic adjustable gastric banding does not meet the TEC criteria; and * bilio-pancreatic diversion and long-limb gastric bypass do not meet the TEC criteria. Anyone know what is going on? If something does not meet the TEC criteria, BCBS does not cover it. Will this effect my approval for my RNY? I'm crapping myself here. I have waited so long and have ony 2 1/2 weeks to go until my surgery. — lindadougherty (posted on June 14, 2003)
June 13, 2003
I have Blue Cross Blue Shield Health options coverage.
My surgery was approved with the first request, within two weeks.
In the latest coverage book it states that BCBS will not cover any weight
loss surgery. However, the rule of thumb for any surgery requests
submitted, is that they must be medically necessary. I suffer from sleep
apnea and GERTS which was enough to gain clearance.
I hope for you the same results.
— Sunshine
June 13, 2003
I have BCBS IL and had surgery throught BTC. What BTC told me is that BCBS
only wanted to pay BTC 8,000 for an over 50,000 surgery. This became
effective June 1, 2003. So I had my surgery May 20. Most surgeons would
agree that 8,000 isn't enough for major surgery and hospital stay.
I would call your surgeon and BCBS to see what they have to say about it.
— Heather M.
June 14, 2003
If your surgeon has already received your pre-authorization from your
insurance company or your laparoscopic RNY, the it would be BAD FAITH for
them to revoke it. If this were to occur, you should call them and tell
them that they are operating in BAD FAITH, if that doesn't work, contact
your state's department of insurance regulation. It is my understanding
that Laparoscopic RNY has the same surgical result (gastric bypass) as open
RNY; therefore, the insurance industry would be hard-pressed to approve
open rather than laparoscopic. However, before you panic, call your
surgeon first, and have their office deal with the insurance compny, if
there's a problem, then follow the above.
Good luck, I'm having laparoscopic RNY on June 25th, and I have New Jersey
BCBS.
— David F.
June 14, 2003
Barb Thompsons great book talks about this. LAP surgery costs more for the
actual surgery but saves hospital days and lessens the risks of hernias.
Both these last two save insurance companies big bucks thats why LAP
surgery has become popular.
— bob-haller
June 14, 2003
theyre all trying to change their policies, but they cannot while your
policy is in effect, midsteam, and they cannot go against State Law.
— gary viscio
June 15, 2003
I think they are just saying they won't pay for the LAP procedure. I also
have BCBS and my surgeon's group have spent a large amount of time
negotiating with BCBS on this exact issue as they do LAP 100% of the time
unless something shows up during surgery. BCBS indicated to the surgeons
that they consider LAP among the "experimental" group and open is
the prefered method. They paid my surgeons the open fee even though my
surgeon did LAP. The difference in fees was $8000. But when will
insurance realize it's not CHEAPER. I was in the hospital from 1:00PM
Friday and went home at 10:00AM Sunday. If I'd had open surgery I probably
would have been in the hospital at least 3 days and those additional days
cost a lot more than the difference in fees for LAP vs. open.
— jutymo
June 15, 2003
My surgeon charges more for Lap and keeps LAP patients in the hospital for
three days. Open stay in two days usually.
— Candace F.
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