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.
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