Understanding Blue Cross

I have Anthem Blue Cross and am in need of revision or conversion surgery. My plan benefit coverage states the criteria for weight loss surgery: bmi, 12 months medically supervised diet program, etc. However, the plan booklet does not give criteria for weight loss revision. It does not mention revision at all. I had the sleeve done in 2010 and 2 months later I was having chemo for breast cancer. With the excessive vomiting that resulted, my sleeve has stretched (surgeon described it as an orange sitting on top of a banana). I have acid reflux, sleep apnea, joint pain, and have regained 70lbs. The surgeon also stated that the sleeve dilation puts me at risk of ulcers.

Anyway, Blue Cross's "Medical Policy" for bariatric surgery does list the criteria for revision (one is pouch dilation due to excessive vomiting) and my revision would qualify as medically necessary. My surgeon has included my situation in his progress notes.

Since my plan does not specifically mention criteria for revision but the insurance's medical policy does, how will Blue Cross base it's decision? I'm gearing up for an appeal via State of CA. I'm so stressed...thanks.

Have you tried calling the number on the back of your card and talking to a live person about this?  That might be useful if you haven't yet.  

If you have - I got nothing, sorry :(

Yes, I called. Rep was just as confused. Thanks.

I deal with insurance authorizations all day long at work. Your surgeon should have someone who works for him who can call and ask some of these questions for you. I call insurance companies on a regular basis and ask questions regarding treatments and procedures. That is one place to start.

As Gwen said, you certainly can call the customer service line. The customer service representative will probably have some information to offer. You also can look online at Anthem's website. When I was going through my own surgery process, I could not find the information I needed online, so I asked customer service to email it to me.

Good luck and be persistent. If your surgeon's office will not properly advocate for you, keep at the insurance company.

RosyKate,

here is what's confusing:

My benefits coverage includes bariatric surgery and lists the criteria that make the surgery medically necessary. It does not mention revision or criteria that make a revision medically necessary.

blue Cross has a general medical policy that says revisions are covered and lists the criteria that make revision of weight loss surgery medically necessary. I meet those criteria.

Would my revision be considered under my benefits coverage criteria or medical policy criteria? Just wondering...

I think they will end up using the medical policy criteria, since your benefits coverage doesn't mention revisions.

If I had to make an educated guess, I would say that what will likely happen is that once the request is submitted, it will go to a medical director for review. That may work in your favor, since an MD will have more of a knowledge base to draw on that a first level reviewer. Also, if you are initially denied for any reason, you can appeal. Sometimes you have to appeal first, and sometimes your doctor can request a peer-to-peer with the medical director, which is good.

I do urge you to have your surgeon's office call and ask these questions. Whomever coordinates authorizations will have access to the provider line, which typically has a bit more information. He or she will also be able to ask specific, in depth questions with your chart at hand. That is typically what I do when I need run across something not clearly spelled out.

Is your insurance through your employer? If so it will be up to the employer if they cover revisions or not. I know many employers that have a "one per lifetime" maximum and others that have no max as long as you meet certain criteria. Employer funded or not, the best way to find out is to contact customer service. They can access your plan and advise if it is covered and if so what you need to do to get it covered.

The benefits booklet that explains what coverage is included does not have any info about revisions at all - does not say if excluded or covered. Weight loss surgery is covered. I spoke with plan administrator and the rep did know what to make of it only that Blue Cross' medical policy covers revisions and my benefits plan does not mention revisions.

Thanks for responding.

I have the same insurance as you - Anthem BCBS and was originally denied for the sleeve although they approved taking out the band. 

The reason for the denial was that they said I did not prove the first surgery worked for me so they would not approve another. They apparently missed in my notes that I lost 80 lbs originally but gained in back after complications with 2 lap band replacement surgeries over a 5 year span. 

My doc sent an appeal showing my weight over the years (original loss and regain)  and an explanation about the gain and I was approved about 3 weeks later. 

I don't believe my policy listed anything about revision either. Hope this helps.

Also, their customer service is a crock. One time I called and was transferred 6 times to be told the dept I needed didn't talk to people on the phone. Only through letters. This was during the appeals process. Each time I called I was transferred at least twice. Very frustrating.