Hello there!  I'm new to the forum, and wondering if anyone else has the same insurance with me, and therefore, the same issues I might be facing.

I'm hoping to undergo weight loss surgery, specifically the sleeve, sometime this year.  I've been following all the steps laid out by Portsmouth hospital.  In the fall, we hit a small snag with my insurance, and within a day of that appointment, I got a letter in the mail stating changes to the insurance benefits.

So I went on ahead with what I was doing.  Fast forward to now (Jan.), and I was told that another patient with the same insurance as me has been denied.  I looked back over the papers I received.  Based on the the letter I got, all plans were affected (HMO, POS, DPOS, and PPO).  The exclusions on obesity have changed.  The exclusion does not apply to surgical procedures specifically intended to result in weight loss (including bariatric surgery) when the health benefit plan or claims administrator (as applicable)-

   -determines surgery is medically necessary; and

   -surgery is limited to one surgical procedure per lifetime regardless (or even) if: and then it lists the reasons.

The way this is worded, it can be interpreted almost two different ways.  Anyone else deal with Independence Blue Cross recently? And if so, what were your outcomes? 

Thanks for reading :)

I'm curious if you ever got your question answered and if so what were the steps you were given in order for aetna to pay for it. I'm also switching from BCBS to Aetna POS ii. Any advice would be helpful. Thanks! 

BCBS has denied my request for conversion surgery.  It seems they look at it as two surgeries:  band removal, which they won't approve because I don't have any catastrophic problems with it; and WLS, which they won't approve because my BMI is too low!

I was banded in 2007 and lost 100 pounds.  I was very successful at keeping it all off for about 5 years.  Then slowly over about a 1.5 to 2 year period I gained back about 30.  I have always had bad reflux, sliming, PBing, etc.  You all know the story.  Now my doc tells me that my esophagus is stretched and she emptied my band.  Of course I gained another almost 30 pounds in about 3 months.  She's been telling me for a couple of years that I should convert to the sleeve and I finally agreed.  After jumping thru all the hoops required by the insurance company, they denied me.  

Has anybody successfully appealed a BCBS decision?  

Hello, Lady!!

I am glad someone reached out.  I feel like I am in uncharted waters.  However, I do have a question or two for you.

How do I even get in a see a Primary?  Do I have to chose that ahead of time?

What about Duke?  I should have done this years ago, but I was TOO scared and now I am regretting it as life takes you where it wants you to go.  :)

I look forward to sharing info with you, but I sorta had given up, but I now have renewed spirit.

Please let me know what you find out and I will do the same.

A

Hi,

I have NC Medicaid too. I talked to my PCP last night. Medicaid covers the surgery, but you are responsible for paying for the pre-op appointments such as tests and the psych evaluation. However, if you go to a practitioner that accepts Medicaid, then I'm assuming you'd pay whatever your normal co-pay is. I'm not 100% sure of this. I'm trying to find answers too. When I find out, I'll let you know. I am trying to decide between 2 hospitals--Wake Forest University Baptist Medical Center in Winston-Salem or Catawba Valley Medical Center in Hickory which is closer for me. For Medicaid patients wanting to have the surgery at Baptist, I was told there was some kind of an 18-month waiting list just to get into the program, which is another reason I'm considering the hospital in Hickory. 

Good luck to you, and like I said I'll let you know what I find out.