BCBS of MA seems particularly picky - ThinnerTimes - Gastric Bypass Forum, Lap Band Forum, and Vertical Sleeve Gastrectomy Forum

laurajh · 09-18-2009, 01:52 PM

I have BCBS of MN and these guys are really making me nervous. Not only do they require the 6 month supervised diet, but they make it very clear that simply showing up for an appointment each month for weigh-ins isn’t enough. They want to see the doctor giving me specific instructions over the course, and her notes indicating whether or not I complied to each suggestion. I had my first visit with her last Friday and all she did was suggest I join Weight Watchers. Jeez, am I going to have to coax her to make suggestions and to document them? A person can be told to cut out sweets, start exercising, etc…only so many times.

Here's my concern. I’m already hovering close to the minimum BMI cutoff, my BMI is 42. It won’t take much for me to drop below the magic BMI threshold. If I lose only 30 or so pounds that will do it (which I’m sure is exactly what the insurance company wants so they can deny me for having "successfully lost weight"). On the other hand, if I DON’T lose that much weight, I probably get accused of failing to comply with my doctor’s recommendations, otherwise I’d be losing more weight over 6 months' time (in which case the insurance company can deny me for failure to comply with the required supervised diet). I feel like I’m in a lose-lose situation. Damned if I do, damned if I don't.

Sure I can lose 30 pounds on my own, I’ve done it before. But I’d bet my life on the fact that this time wouldn’t be any different and I’d end up putting it right back on again. I can lose a small amount of weight on my own. What I CAN’T do is lose 100. And I certainly wouldn't be able to keep it off if I did.

I also get the impression that my primary isn’t exactly pro surgery. She hasn’t tried to talk me out of it or badmouthed it, but I get the sense she’s more against it than for it, and is only humoring me because she has to be professional. I don’t know if her personal views are going to hinder me in any way. Who knows what she'll be putting on that paperwork! She tells me that with Weight Watchers, good eating habits will become second nature (ha! funny little lady). She didn’t come out and say so, but I can tell she’s thinking I won’t need surgery because WW will work for me. She has to remain professional and respectful enough to “humor the patient” but I do get the feeling she’s one of those “just eat right and exercise ya lazy couch potato!” people. And of course I should mention that she’s skinny as a rail without an ounce of fat on her, so she doesn’t know what it’s like to fight with your weight your entire life. I wanted to take her stethoscope and strangle her with it.

laurajh · 09-18-2009, 01:53 PM

I meant to say I have BCBS of MINNESOTA, not MA.
(great big dope slap upside the head for me)

mistymee · 09-18-2009, 02:31 PM

Quote:

Originally Posted by laurajh

I meant to say I have BCBS of MINNESOTA, not MA.
(great big dope slap upside the head for me)

Hi hon.. sorry I can't help you with the insurance issues.. I had no issues at ALL!

(and funny I *did* have BCBS of MA. lol)

If you wanna edit the title go to the edit button, then click ADVANCED edit..and you can correct that.

HTH

Vikkator · 09-18-2009, 02:38 PM

What you're encountering is something many of us dealt with. Before you submit anything to the bariatric surgeon, make sure you see what your PCP is going to submit, and make sure you agree with it. Otherwise you run the risk of it not saying what you want it to say.

My bmi was 39.5 with no co-morbids when I started and I was told by my nutritionist that I shouldn't try to lose much weight or I'd be disqualified. She also told me not to gain any since I was supposed to be on a supervised diet. So I lost 8 pounds in 6 months and I was still approved. However, I had United Healthcare, not BCBS. I had a history a mile long of weight loss successes and then again failures, which my PCP was keenly aware of. He submitted documentation stating that fact.

My PCP was all for it and knew the surgeon, who he highly recommended. If you find you're up against a brick wall with your PCP, it might be time to find a new one. You don't want her standing in your way and I've seen where some docs end up sabotaging their patients because they have that Weight Watchers mentality.

By the way, I was on WW for many years. It didn't work for me. It's a great and healthy program, and I think it works well for people who are 30-40 pounds overweight, but for people like us, it's not a permanent solution.

poet_kelly · 09-19-2009, 12:34 PM

I don't know if that's any pickier than most insurance companies. I know it's a pain in the butt, though.

Are you comfortable with this PCP? Do you feel a different PCP might be more supportive? Don't hesitate to find a new one if you think it might help or you would just feel better.

You said she recommended Weight Watchers. Are you joining? 'Cause if that's what she wrote down as her recommendation, and you don't compy, is that going to cause a problem with your insurance?

Kelly

lisav0218 · 09-19-2009, 12:49 PM

I have BCBS of Alabama and the only issue I had was they kept saying the didn't recieve all my info that was faxed. Finally my nurse had to call and sit down and fax 1 paper at a time and once they recieved it all I got approved!!

lisav0218 · 09-19-2009, 12:50 PM

I have BCBS of Alabama and the only issue I had was they kept saying the didn't recieve all my info that was faxed. Finally my nurse had to call and sit down and fax 1 paper at a time and once they recieved it all I got approved!!

I hope you get approval, wishing you the best!

netta · 09-19-2009, 01:11 PM

I have BCBS of Minn.
I went to my 6 month visits faithfully each month, and I was informed that they take the starting BMI, even if you lost weight. They didn't re-evaluate if you lost weight.

I had no issues at all getting aproved.

samtherockstar85 · 09-19-2009, 07:45 PM

When I first started out I had this PCP that also told me to go to weight watchers....I stopped seeing her after a few visits and found the awesome doctor I have now. I suggest you try a new doctor too. It's I best thing I've done for myself.

Josephine · 09-19-2009, 11:43 PM

Ya never know hon. Even skinny people might struggle with their weight in secret. She might have to go to the gym everyday and only eat 3 meals a day to stay that size. She MIGHT understand. Also, I've known 2 people in my life that I've actually had cry to me about being too skinny and being unable to gain weight. It's heartbreaking for them. My boss was a size 0 with her skirt falling down.... do you think she felt beautiful and was rubbing it in? Nooo way.

My point is that we never know someone elses struggles and temptations and addictions, and nearly all of us have them.

My process here is very different, we don't fight with insurance companies. They just do what PCPs and surgeons say. Getting approved was never an issue, but I can tell you that from studying this surgery intensely for the last 15 months, I think you will be FINE. My opinion? You have a BMI of 42. Keep the doc you've started with, do the 6 months, lose 15 to 20 lbs to make everyone happy, and enjoy your win. They won't deny you if you do the diet and have a BMI over 40. And, if they have that deny everyone game going on, you'd easily win an appeal. I don't think you have anything to worry about... but of course I wasn't there, so go with your heart on what you think is right.

I don't believe the 6 month supervised diet is there for the insurance companies to be able to deny people. It's there to prove to your PCP and surgeon that you can follow instructions, as well as to help train you and shrink the liver so it's easier for the surgeon to operate. But most importantly, I believe it's there to give you one last shot to change your mind. What if you get started on the program, and you're on fire, go all biggest loser on them - eating 1200 cal of protein/veggies a day and exercising 4 or 5 hours a day in the gym. You could inspire yourself enough to go all the way. Lord knows I'd go all Rambo and give it one last big shot if I didn't have all this pain. They're just giving you that one last chance to decide what your path is.

*hug* I wish you strength. You'll be fine!