Will this insurance pay for surgery?

Question

will bcbs pay for gastric-by pass or lap band surgery? do you think its a good idea to get it. put it this way any suggestions on why you think a person should get this. i know the 1st reason will be of course OBESITY, but any other reasons. please answer all if possible and please be kind.

Answer 1

Hi Classy.

Kathy is correct in her suggestion to call BCBS customer service. I am a Broker with BCBS and each case is different in this particular instance. BCBS will underwrite each situation based on doctor reports, lab results, etc. I have seen one person be approved and another declined. I am not exactly sure what deciding factors they base their decisions on, but it is individual.

As far as By-pass surgery, exhaust ALL other options first! My wife was considering having the surgery, and we found the mortality rates and long term side effects are horrible. The Lap band process seemed a much easier process, and I couldn't find any deaths as a result of the procedure. Neither is exactly a true long term fix, due to the nature of the procedure, but if there are no other options, then opt for the Lap band.

My wife has opted for a weight loss clinic in which the doctor has included a dietitian, a counselor, and other resources available (included in the price) to her any time she needs. She gets a shot once a week that has B-12 and other things to help with cravings and mood swings. She also gets a prescription each month to help lower her appetite. Our insurance would not pay for the service, so we pay it each month out of pocket. It cost $150 mo., which I know can be a lot, but the cut backs on less healthy foods has almost made up the difference.

I hope this helps. I wish you success on your journey. God Bless!

Answer 2

Usually, BCBS only covers medically necessary surgery.  When it comes to obesity, you have to be morbidly obese for them to pay.  You should have your doctor do a pre-determination of benefits so that the procedure is covered.  When the doctor does this, he will send a letter indicating what procedure he will do and will include any supporting information, including a history and physical.

Answer 3

Hello there Classy,

From my 7 1/2 years of working for a health insurance company, I will let you know that gastric bypass is foremost covered as a function of a patient's BMI (Body Mass Index).  If a patient doesn't have the BMI to qualify alone for the surgery, they will look at if the patient has other co-moridities (health conditions that are considered risk factors) such as High Blood Pressure, arthritis that results in knee joint/hip joint damage that may require replacement, diabetes, etc.  

You should be able to contact the BCBS customer service department and ask them to provide you for a copy of the authorization guidelines for the surgery.  I believe they will disclose that to you.  

I hope that information proves helpful.

Good luck!

Kathy K

www.premiumwatchdog.com

Answer 4

It's going to depend on your plan, and what state you are in.

I think it's a bad idea to get it.  Studies show that five years after surgery, the vast majority of recipients are at their presurgery weight, or over.    Plus, there are very real risks of complications and death, just from the surgery.  

I'd strongly suggest, first of all, a visit to a spectacular endocrinologist in your area, to rule out a problem there, followed by a lifestyle change, including changing the types of food you eat, and mild excercising.  You can eat as much as you want, but if you cut starches and fats, you'll lose tons of weight.  The rabbit diet is VERY healthy, doesn't have the risks of surgery, and is a lifelong doable thing.

Answer 5

My cousin recently got denied for her lap band surgery, so I can give you a second reason to get the surgery.

BCBS asked her to show doctors records that she had been 100 lbs overweight for at least the past 3-4 years. Plus, the doctor told her that if they could show that she had sleep apnea as a result of her weight, that would help her case. (She really did have sleep apnea, but had never been formally tested for it.)

The day that she was to go to the sleep lab for the apnea test, BCBS denied her claim for the lap band surgery, saying that she hadn't proven that she was significantly overweight for the 3 year period of time.

That absolutely wasn't true. She had been within the proper weight range to get the lap band surgery. But she was denied anyway because one of the out-of-state doctors couldn't be contacted.  

Answer 6

Some States are now passing regulations to force health care insurance to cover these types of 'elective surgeries' (which of course will make premiums go up).  I think it is a good surgery as a last resort and will only be successful if the patient is committed to changing their life-style and eating habits (which is what got them into their situation in the first place).  There are many instances where this surgery was a complete success and and many instances where the patient did not change their habits and re-gained the weight.