Re: Federal Blue Cross [Cross Post]

[Guest guest]

Hi Gobo,

I'm glad to see you posting. I hope you're doing well!

In regards to Fed BCBS and the DS surgery. Yes, the lack of specific

CPT code is a problem for BCBS Fed BUT they do say that the DS is

still experimental and investigative. It is currently under " task

review " in Chicago but according to the national office of BCBS Fed

in Washington DC the DS is still on their E & I list.

Surgeries can come off of this list w/o having a specific CPT code.

BCBC Fed told me they were only going to pay for the " gastric bypass "

portion of my bill but when I got my statement from Dr 's

office they had paid a portion of 43633 and 43847. I still have not

been sent an EOB (explanation of benefits). I was told that I may not

receive this until the task review is complete.

The DC office is very aware of this problem. If anyone is having any

problems with their local (state) office call the DC office. I was

told that my surgery was flat out denied by the Oregon Fed office

because it was E & I. Thanks to Judi in MS who got me in touch w/ the

DC office.

The name for our surgery that Dr is now using IS the

DESCRIPTION of CPT code 43847. Dr Gagner IS correct in saying that

the DS surgery is not covered by BCBS Fed in NY. Do people still get

this surgery paid for? Yes. Sometimes it slips through with the CPT

code 43847 which can also be used for a " Distal RNY " surgery. Other

times (like myself) we have to take it to DC or OPM to have them

handle it vs the local state office. I haven't heard of it ever being

denied completely.

Let me know if I can provide further clarification. I feel I could

write a book on the subject!

LAP DS Dr 1/23/01

268 BMI 42

182 BMI 28

> I am posting here, my answer to a private email.

> I do not know which list the writer is on, so I am going to cross-

post this.

> I hope this serves to help de-mystify the business about Blue Cross

denying the DS.

>

> I do not believe that the problem is with Blue Cross but with the

lack of CPT code.

>

> In the absence of a CPT code, there are ways to circumvent this

problem. The solution

> lies in coding the procedure according to a description of what is

being done rather

> than coding according to a uniformed title (BPD/DS).

>

> Please read:

>

> Hi;

> I believe that Dr. Gagner is confused.

> My OWN surgeon, Dr. Emma did her fellowship under Dr.

Gagner. That means

> that everything she learned about Bariatric Surgery, she learned

from Dr. Gagner.

> However, she always makes it clear that 'Billing' and 'Insurance'

are not part of a

> surgeon's area of expertise.

>

> Dr. Gagner mentioned to you 'Fed/NY Blue Cross'.

> There is no such thing as 'Federal-New York' Blue Cross.

>

> Dr. Gagner is taking information that may or may not be true for

the Statewide New

> York Blue Cross and combining it with information that I believe to

be in error about

> FEDERAL Blue Cross.

>

> Also, the Federal Blue Cross in your state at least tried to point

you in the right

> direction. The billing would in fact go through the Federal Blue

Cross office that is

> local to New York.

>

> Please realize that this is not the same office as the State Blue

Cross office that is

> located in New York.

>

> Each state has Blue Cross of that particular state and also, the

Federal Blue Cross has

> offices in that state. They are related only in name; not in

policies, rules or

> administration.

>

> I myself live in the State of Washington but had my surgery in the

Sate of Oregon. I

> fully understand what you tried to explain to me. The problem is

that folks who have

> Federal Blue Cross keep getting mis-information because of the

state-wide Blue

> Cross.

>

> Also, the Federal Blue Cross of New York would be hard pressed to

try to deny

> something that is covered in all other states. The reason is

simple, Federal Blue Cross

> is a federal, nation-wide insurance policy. We all have the exact

same policy. Our

> policies do not depend on what state we live in. One state cannot

deny something

> based on what Blue Cross for a particular state denies unless all

Blue Cross in all

> states denies it.

>

> Getting back to Dr. Gagner and his belief that it is not covered in

New York: I believe

> that the problem lies in the way the procedure is coded. I believe

that Blue Cross (and

> other insurance carriers) have a problem with " BPD/DS " .

>

> Dr. now uses a long protracted procedure name. There are

about 16 words

> total in the name. It starts out with, DGB or, " Distal Gastric

Bypass " . The description

> goes on and on.

>

> Dr. Rabkin also does the DS using this description.

>

> As far as I know, both Dr. Rabkin and Dr. get reimbursed

for this procedure.

> The only difference is the way it is described to the insurance

company for billing

> purposes. Medically, there is absolutely no difference in what

surgery we get.

>

> By the way, the fault is not so much with the insurance companies.

I know that

> surgeons' offices and thwarted patients would have us think

otherwise. The problem

> is that there is yet to be an agreed upon CPT code for the DS

itself. That is something

> that just is going to have to take time in happening. The ASBS is

trying to see this

> happen.

>

> This is the way I understand it.

>

> If you go to a restaurant that has lots of fancy dinners and they

are each ordered by

> an item number, that is fine, unless you want to order a fancy

dinner that does not

> have a corresponding item number.

>

> Let's say, you want something, but the only way to get it is to

order each item

> individually. You might say, " I'll have the steak, broiled medium-

rare, sliced very thin "

> (for London Char-broiled); " I'll have a baked potato w/chives;

peas; salad; . . . "

> In other words, you might be able to STILL get exactly what you

want but you might

> have to describe it in detail and order it a la carte.

>

> Well, the BPD/DS is complex enough that there are acceptable

surgical descriptions

> for this procedure that taken together, each have the requisite CPT

codes.

>

> I would pursue this further. I don't see the problem as being the

insurance. We have

> one of the more liberal ones. The policy even says that 'gastric

bypass' is a covered

> procedure. There is no disclaimer to exclude one procedure over

another. Please look

> at page 41 of our Federal Policy Book.

>

> If you need anymore help, please let me know.

>

> By the way, I just reread your message and saw you were talking to

Blue Cross-The

> Empire Plan. That doesn't sound like Federal Blue Cross to me. That

sounds like the

> state-wide Blue Cross for New York. If you call your federal Blue

Cross, ask them for

> the telephone number for FEDERAL BLUE CROSS in New York. This

really is different

> than the state-wide plan. Here in Washington (state) there is a

separate office and

> phone number for Blue Cross of Washington versus Federal Blue Cross

for Washington

> residents.

>

> I know this seems like hell but it is worth it. The problem you're

having right now is

> with the surgeon's offices ignorance, not the insurance itself.

>

> Good luck.

>

> gobo

[Guest guest]

Hi Gobo,

I'm glad to see you posting. I hope you're doing well!

In regards to Fed BCBS and the DS surgery. Yes, the lack of specific

CPT code is a problem for BCBS Fed BUT they do say that the DS is

still experimental and investigative. It is currently under " task

review " in Chicago but according to the national office of BCBS Fed

in Washington DC the DS is still on their E & I list.

Surgeries can come off of this list w/o having a specific CPT code.

BCBC Fed told me they were only going to pay for the " gastric bypass "

portion of my bill but when I got my statement from Dr 's

office they had paid a portion of 43633 and 43847. I still have not

been sent an EOB (explanation of benefits). I was told that I may not

receive this until the task review is complete.

The DC office is very aware of this problem. If anyone is having any

problems with their local (state) office call the DC office. I was

told that my surgery was flat out denied by the Oregon Fed office

because it was E & I. Thanks to Judi in MS who got me in touch w/ the

DC office.

The name for our surgery that Dr is now using IS the

DESCRIPTION of CPT code 43847. Dr Gagner IS correct in saying that

the DS surgery is not covered by BCBS Fed in NY. Do people still get

this surgery paid for? Yes. Sometimes it slips through with the CPT

code 43847 which can also be used for a " Distal RNY " surgery. Other

times (like myself) we have to take it to DC or OPM to have them

handle it vs the local state office. I haven't heard of it ever being

denied completely.

Let me know if I can provide further clarification. I feel I could

write a book on the subject!

LAP DS Dr 1/23/01

268 BMI 42

182 BMI 28

> I am posting here, my answer to a private email.

> I do not know which list the writer is on, so I am going to cross-

post this.

> I hope this serves to help de-mystify the business about Blue Cross

denying the DS.

>

> I do not believe that the problem is with Blue Cross but with the

lack of CPT code.

>

> In the absence of a CPT code, there are ways to circumvent this

problem. The solution

> lies in coding the procedure according to a description of what is

being done rather

> than coding according to a uniformed title (BPD/DS).

>

> Please read:

>

> Hi;

> I believe that Dr. Gagner is confused.

> My OWN surgeon, Dr. Emma did her fellowship under Dr.

Gagner. That means

> that everything she learned about Bariatric Surgery, she learned

from Dr. Gagner.

> However, she always makes it clear that 'Billing' and 'Insurance'

are not part of a

> surgeon's area of expertise.

>

> Dr. Gagner mentioned to you 'Fed/NY Blue Cross'.

> There is no such thing as 'Federal-New York' Blue Cross.

>

> Dr. Gagner is taking information that may or may not be true for

the Statewide New

> York Blue Cross and combining it with information that I believe to

be in error about

> FEDERAL Blue Cross.

>

> Also, the Federal Blue Cross in your state at least tried to point

you in the right

> direction. The billing would in fact go through the Federal Blue

Cross office that is

> local to New York.

>

> Please realize that this is not the same office as the State Blue

Cross office that is

> located in New York.

>

> Each state has Blue Cross of that particular state and also, the

Federal Blue Cross has

> offices in that state. They are related only in name; not in

policies, rules or

> administration.

>

> I myself live in the State of Washington but had my surgery in the

Sate of Oregon. I

> fully understand what you tried to explain to me. The problem is

that folks who have

> Federal Blue Cross keep getting mis-information because of the

state-wide Blue

> Cross.

>

> Also, the Federal Blue Cross of New York would be hard pressed to

try to deny

> something that is covered in all other states. The reason is

simple, Federal Blue Cross

> is a federal, nation-wide insurance policy. We all have the exact

same policy. Our

> policies do not depend on what state we live in. One state cannot

deny something

> based on what Blue Cross for a particular state denies unless all

Blue Cross in all

> states denies it.

>

> Getting back to Dr. Gagner and his belief that it is not covered in

New York: I believe

> that the problem lies in the way the procedure is coded. I believe

that Blue Cross (and

> other insurance carriers) have a problem with " BPD/DS " .

>

> Dr. now uses a long protracted procedure name. There are

about 16 words

> total in the name. It starts out with, DGB or, " Distal Gastric

Bypass " . The description

> goes on and on.

>

> Dr. Rabkin also does the DS using this description.

>

> As far as I know, both Dr. Rabkin and Dr. get reimbursed

for this procedure.

> The only difference is the way it is described to the insurance

company for billing

> purposes. Medically, there is absolutely no difference in what

surgery we get.

>

> By the way, the fault is not so much with the insurance companies.

I know that

> surgeons' offices and thwarted patients would have us think

otherwise. The problem

> is that there is yet to be an agreed upon CPT code for the DS

itself. That is something

> that just is going to have to take time in happening. The ASBS is

trying to see this

> happen.

>

> This is the way I understand it.

>

> If you go to a restaurant that has lots of fancy dinners and they

are each ordered by

> an item number, that is fine, unless you want to order a fancy

dinner that does not

> have a corresponding item number.

>

> Let's say, you want something, but the only way to get it is to

order each item

> individually. You might say, " I'll have the steak, broiled medium-

rare, sliced very thin "

> (for London Char-broiled); " I'll have a baked potato w/chives;

peas; salad; . . . "

> In other words, you might be able to STILL get exactly what you

want but you might

> have to describe it in detail and order it a la carte.

>

> Well, the BPD/DS is complex enough that there are acceptable

surgical descriptions

> for this procedure that taken together, each have the requisite CPT

codes.

>

> I would pursue this further. I don't see the problem as being the

insurance. We have

> one of the more liberal ones. The policy even says that 'gastric

bypass' is a covered

> procedure. There is no disclaimer to exclude one procedure over

another. Please look

> at page 41 of our Federal Policy Book.

>

> If you need anymore help, please let me know.

>

> By the way, I just reread your message and saw you were talking to

Blue Cross-The

> Empire Plan. That doesn't sound like Federal Blue Cross to me. That

sounds like the

> state-wide Blue Cross for New York. If you call your federal Blue

Cross, ask them for

> the telephone number for FEDERAL BLUE CROSS in New York. This

really is different

> than the state-wide plan. Here in Washington (state) there is a

separate office and

> phone number for Blue Cross of Washington versus Federal Blue Cross

for Washington

> residents.

>

> I know this seems like hell but it is worth it. The problem you're

having right now is

> with the surgeon's offices ignorance, not the insurance itself.

>

> Good luck.

>

> gobo

[Guest guest]

;

Sorry if I spoke incorrectly about Dr. Gagner's office and about Fed.

Blue Cross of New

York.

I am not personally aware of BC/BS having the perogative to deny

something in some

states and not in others.

I am aware of folks being denied something but, under appeal they

were covered due

to what I had mentioned in my own post: BC/BS cannot pick and chooses

which states

to cover a procedure in and what states to deny it. That has been my

experience but

if you know more about Dr. Gagner and BC of New York, I will defer

folks to your own

expertise.

For myself, I have always approaced a problem with the outlook that I

must be

treated with the same degree of fairness as others in my similar

class. I've had lots of

experience challenging inequities when I worked for the government

and I was

always successful. Perhaps it was just luck.

Good luck with your own endeavor. I have had zero problem so far in

having my

surgery covered 100%.

While this is no guarantee as to what others' experience will be, I

think it sets a

precendence that others are entitled to expect the same.

Obviously, you know something about Dr. Gagner and Federal BC in New

York that

goes beyond the scope of my own knowledge and experience.

Good luck

gobo

> Hi Gobo,

>

> I'm glad to see you posting. I hope you're doing well!

>

> In regards to Fed BCBS and the DS surgery. Yes, the lack of

specific

> CPT code is a problem for BCBS Fed BUT they do say that the DS is

> still experimental and investigative. It is currently under " task

> review " in Chicago but according to the national office of BCBS Fed

> in Washington DC the DS is still on their E & I list.

>

> Surgeries can come off of this list w/o having a specific CPT code.

>

> BCBC Fed told me they were only going to pay for the " gastric

bypass "

> portion of my bill but when I got my statement from Dr 's

> office they had paid a portion of 43633 and 43847. I still have not

> been sent an EOB (explanation of benefits). I was told that I may

not

> receive this until the task review is complete.

>

> The DC office is very aware of this problem. If anyone is having

any

> problems with their local (state) office call the DC office. I was

> told that my surgery was flat out denied by the Oregon Fed office

> because it was E & I. Thanks to Judi in MS who got me in touch w/ the

> DC office.

>

> The name for our surgery that Dr is now using IS the

> DESCRIPTION of CPT code 43847. Dr Gagner IS correct in saying that

> the DS surgery is not covered by BCBS Fed in NY. Do people still

get

> this surgery paid for? Yes. Sometimes it slips through with the CPT

> code 43847 which can also be used for a " Distal RNY " surgery. Other

> times (like myself) we have to take it to DC or OPM to have them

> handle it vs the local state office. I haven't heard of it ever

being

> denied completely.

>

> Let me know if I can provide further clarification. I feel I could

> write a book on the subject!

>

>

>

> LAP DS Dr 1/23/01

> 268 BMI 42

> 182 BMI 28

[Guest guest]

Hi Gobo,

I don't think my post was very clear so let me try again! According

to in the Fed BCBS national office in Wash DC the DS

surgery is considered to be experimental and investigative by Fed

BCBS in ALL 50 STATES. HOWEVER! Some states such as Nebraska take on

their local state policy and cover the DS outright. I spoke to the

medical director Dr Mellion in Nebraska and he said they do not

believe the surgery is E & I. Then there are other states such as

Oregon where the 3 other DS surgeries that were performed were paid

with CPT codes 43847 and 43633. I was told that when this happens

they didn't know these were DS surgeries. They thought they were

distal RNY's, even though when I talked to Dr Welker regarding this

he told me that he puts " Lateral Gastrectomy with Duodenal Switch "

right on the paperwork. Mine was denied due to an unlisted lap code

the term " BPD " and the op notes. By the time the office submitted the

usual and customary codes for the DS 43847 and 43633 the red flag was

already raised and it was denied again.

So, having said all this is the practice of covering it in some

states and not in others " uneven distribution of company policy " ?

ABSOLUTELY!!! and the Wash DC office is VERY AWARE of this and VERY

SENSITIVE to it! All the Federal plans are very cautious about

discrimination of their members because they know we have OPM looking

over their shoulder. BCBS is trying to right the situation. That is

why they sent the DS to " task review " in Chicago even though the DS

surgery was under task review and subsequently denied in July of

2000. They are willing to take a look at it again because so many

(approx 20) members have had the DS and Fed BCBS have paid their

claims.

As I stated before Fed BCBS seems to be paying for all of my surgery.

I believe they will pay for all the others because they have set a

historical precedance by covering the DS for other members.

Hope this helps to clarify things better. Take care.

> > Hi Gobo,

> >

> > I'm glad to see you posting. I hope you're doing well!

> >

> > In regards to Fed BCBS and the DS surgery. Yes, the lack of

> specific

> > CPT code is a problem for BCBS Fed BUT they do say that the DS is

> > still experimental and investigative. It is currently under " task

> > review " in Chicago but according to the national office of BCBS

Fed

> > in Washington DC the DS is still on their E & I list.

> >

> > Surgeries can come off of this list w/o having a specific CPT

code.

> >

> > BCBC Fed told me they were only going to pay for the " gastric

> bypass "

> > portion of my bill but when I got my statement from Dr

's

> > office they had paid a portion of 43633 and 43847. I still have

not

> > been sent an EOB (explanation of benefits). I was told that I may

> not

> > receive this until the task review is complete.

> >

> > The DC office is very aware of this problem. If anyone is having

> any

> > problems with their local (state) office call the DC office. I

was

> > told that my surgery was flat out denied by the Oregon Fed office

> > because it was E & I. Thanks to Judi in MS who got me in touch w/

the

> > DC office.

> >

> > The name for our surgery that Dr is now using IS the

> > DESCRIPTION of CPT code 43847. Dr Gagner IS correct in saying

that

> > the DS surgery is not covered by BCBS Fed in NY. Do people still

> get

> > this surgery paid for? Yes. Sometimes it slips through with the

CPT

> > code 43847 which can also be used for a " Distal RNY " surgery.

Other

> > times (like myself) we have to take it to DC or OPM to have them

> > handle it vs the local state office. I haven't heard of it ever

> being

> > denied completely.

> >

> > Let me know if I can provide further clarification. I feel I

could

> > write a book on the subject!

> >

> >

> >

> > LAP DS Dr 1/23/01

> > 268 BMI 42

> > 182 BMI 28

[Guest guest]

So if you are in the pre-op phase with BCBS FED PPO, should you wait

for the dust to clear or proceed and risk denial? I just am not sure.

My message from Dr. K's office was uncertain about coverage, they

have a few patients who have had their surgery but BCBS did NOT

ultimately pay. YIKES! I am going to get in touch with Dr.

soon and see what she thinks. Dr. Gagner was pretty confident it

would no longer go through. As if it wasn't hard enough to get things

approved! I have a " go ahead " a " we're not sure " and a " no. "

NOW WHAT??????

To top it all off in my case I do not have a PCP and I live in a

state where no one does the procedure. Well it may take some time,

but I don't want to give up.

> > > Hi Gobo,

> > >

> > > I'm glad to see you posting. I hope you're doing well!

> > >

> > > In regards to Fed BCBS and the DS surgery. Yes, the lack of

> > specific

> > > CPT code is a problem for BCBS Fed BUT they do say that the DS

is

> > > still experimental and investigative. It is currently

under " task

> > > review " in Chicago but according to the national office of BCBS

> Fed

> > > in Washington DC the DS is still on their E & I list.

> > >

> > > Surgeries can come off of this list w/o having a specific CPT

> code.

> > >

> > > BCBC Fed told me they were only going to pay for the " gastric

> > bypass "

> > > portion of my bill but when I got my statement from Dr

> 's

> > > office they had paid a portion of 43633 and 43847. I still have

> not

> > > been sent an EOB (explanation of benefits). I was told that I

may

> > not

> > > receive this until the task review is complete.

> > >

> > > The DC office is very aware of this problem. If anyone is having

> > any

> > > problems with their local (state) office call the DC office. I

> was

> > > told that my surgery was flat out denied by the Oregon Fed

office

> > > because it was E & I. Thanks to Judi in MS who got me in touch w/

> the

> > > DC office.

> > >

> > > The name for our surgery that Dr is now using IS the

> > > DESCRIPTION of CPT code 43847. Dr Gagner IS correct in saying

> that

> > > the DS surgery is not covered by BCBS Fed in NY. Do people still

> > get

> > > this surgery paid for? Yes. Sometimes it slips through with the

> CPT

> > > code 43847 which can also be used for a " Distal RNY " surgery.

> Other

> > > times (like myself) we have to take it to DC or OPM to have

them

> > > handle it vs the local state office. I haven't heard of it ever

> > being

> > > denied completely.

> > >

> > > Let me know if I can provide further clarification. I feel I

> could

> > > write a book on the subject!

> > >

> > >

> > >

> > > LAP DS Dr 1/23/01

> > > 268 BMI 42

> > > 182 BMI 28

[Guest guest]

Dear Danine,

I know exactly how you feel! It is very frustrating and scary to go

through this process w/ Fed BCBS. The main thing you can do is press

for a " Pre-Authorization " not a " Pre-Cert " . They say that they

stopped doing pre-auth in June of 2000 but they still do them. This

way you can go through the denial process before and have the pre-

auth before surgery.

The other option (the one that I would choose) is to go ahead with

the surgery (if Dr K will) and deal with the insurance afterwards.

Do you know what BCBS the patients had that were denied? The BCBS

plans within any given sate can run the gamet of completely paying

for the DS to having an iron-clad exclusion for ANY WLS. If you know

of any Fed BCBS member that has been denied benefits please send them

my way.

I only had to go as far as the Washington DC office but we always

have OPM to appeal to if needed.

I talked to Fed BCBS in Oregon today and they are going to send a

copy of my " Explanation of Benefits " . I will be happy to fax you a

copy when I recieve it so you can show it to Dr K's insurance person.

I can also provide more information for them if you need it. E-mail

me privately with your fax # if you'd like.

In the meantime try not to stress too much.

Best of luck to you.

Lap DS Dr 1/23/01

268 BMI 42

182 BMI 28

> > > > Hi Gobo,

> > > >

> > > > I'm glad to see you posting. I hope you're doing well!

> > > >

> > > > In regards to Fed BCBS and the DS surgery. Yes, the lack of

> > > specific

> > > > CPT code is a problem for BCBS Fed BUT they do say that the

DS

> is

> > > > still experimental and investigative. It is currently

> under " task

> > > > review " in Chicago but according to the national office of

BCBS

> > Fed

> > > > in Washington DC the DS is still on their E & I list.

> > > >

> > > > Surgeries can come off of this list w/o having a specific CPT

> > code.

> > > >

> > > > BCBC Fed told me they were only going to pay for the " gastric

> > > bypass "

> > > > portion of my bill but when I got my statement from Dr

> > 's

> > > > office they had paid a portion of 43633 and 43847. I still

have

> > not

> > > > been sent an EOB (explanation of benefits). I was told that I

> may

> > > not

> > > > receive this until the task review is complete.

> > > >

> > > > The DC office is very aware of this problem. If anyone is

having

> > > any

> > > > problems with their local (state) office call the DC office.

I

> > was

> > > > told that my surgery was flat out denied by the Oregon Fed

> office

> > > > because it was E & I. Thanks to Judi in MS who got me in touch

w/

> > the

> > > > DC office.

> > > >

> > > > The name for our surgery that Dr is now using IS

the

> > > > DESCRIPTION of CPT code 43847. Dr Gagner IS correct in saying

> > that

> > > > the DS surgery is not covered by BCBS Fed in NY. Do people

still

> > > get

> > > > this surgery paid for? Yes. Sometimes it slips through with

the

> > CPT

> > > > code 43847 which can also be used for a " Distal RNY " surgery.

> > Other

> > > > times (like myself) we have to take it to DC or OPM to have

> them

> > > > handle it vs the local state office. I haven't heard of it

ever

> > > being

> > > > denied completely.

> > > >

> > > > Let me know if I can provide further clarification. I feel I

> > could

> > > > write a book on the subject!

> > > >

> > > >

> > > >

> > > > LAP DS Dr 1/23/01

> > > > 268 BMI 42

> > > > 182 BMI 28

[Guest guest]

Danine,

I forgot to respond to your last paragraph. I live in San Diego and

went to Portland OR for my Lap DS. There are no DS surgeons in San

Diego so I found a very supportive, open-minded internist and

" educated " her on the DS surgery. She has RNY patients so she was

familiar with some of the issues. The main thing was that she was

completely receptive and supportive. This is key for out of state

people because she did my 3 month (and will do subsequent) follow-up

appts and bloodwork. She faxed me a copy of my bloodwork and I in

turn faxed them to Dr . We then had a phone appt. It's

working just fine.

Good Luck.

P.S. I'd be happy to call Dr K's insurance person if you'd like. Let

me know.

> > > > Hi Gobo,

> > > >

> > > > I'm glad to see you posting. I hope you're doing well!

> > > >

> > > > In regards to Fed BCBS and the DS surgery. Yes, the lack of

> > > specific

> > > > CPT code is a problem for BCBS Fed BUT they do say that the

DS

> is

> > > > still experimental and investigative. It is currently

> under " task

> > > > review " in Chicago but according to the national office of

BCBS

> > Fed

> > > > in Washington DC the DS is still on their E & I list.

> > > >

> > > > Surgeries can come off of this list w/o having a specific CPT

> > code.

> > > >

> > > > BCBC Fed told me they were only going to pay for the " gastric

> > > bypass "

> > > > portion of my bill but when I got my statement from Dr

> > 's

> > > > office they had paid a portion of 43633 and 43847. I still

have

> > not

> > > > been sent an EOB (explanation of benefits). I was told that I

> may

> > > not

> > > > receive this until the task review is complete.

> > > >

> > > > The DC office is very aware of this problem. If anyone is

having

> > > any

> > > > problems with their local (state) office call the DC office.

I

> > was

> > > > told that my surgery was flat out denied by the Oregon Fed

> office

> > > > because it was E & I. Thanks to Judi in MS who got me in touch

w/

> > the

> > > > DC office.

> > > >

> > > > The name for our surgery that Dr is now using IS

the

> > > > DESCRIPTION of CPT code 43847. Dr Gagner IS correct in saying

> > that

> > > > the DS surgery is not covered by BCBS Fed in NY. Do people

still

> > > get

> > > > this surgery paid for? Yes. Sometimes it slips through with

the

> > CPT

> > > > code 43847 which can also be used for a " Distal RNY " surgery.

> > Other

> > > > times (like myself) we have to take it to DC or OPM to have

> them

> > > > handle it vs the local state office. I haven't heard of it

ever

> > > being

> > > > denied completely.

> > > >

> > > > Let me know if I can provide further clarification. I feel I

> > could

> > > > write a book on the subject!

> > > >

> > > >

> > > >

> > > > LAP DS Dr 1/23/01

> > > > 268 BMI 42

> > > > 182 BMI 28

[Guest guest]

Thank you so very much on the clarity of your posts regarding this

insurance issue. It means a great deal to me as I have NOT been

comfortable for a month now with proceeding.

I am now planning to come to Oregon for the ds with Dr.

. I have had a few emails really recommending her and have

had an offer to stay with an AMOS member instead of the hotel. Money

is a very difficult issue right now, so that would help.

I will look locally for a supportive internist and go from

there. Maybe by the time I get submitted it won't be a cause for

concern. I heard there is a lot of support in Portland. Coming from

the hot desert of Phoenix, will I want to return after I vist the

coast? Hmmmmmmm.

> > > > > Hi Gobo,

> > > > >

> > > > > I'm glad to see you posting. I hope you're doing well!

> > > > >

> > > > > In regards to Fed BCBS and the DS surgery. Yes, the lack of

> > > > specific

> > > > > CPT code is a problem for BCBS Fed BUT they do say that the

> DS

> > is

> > > > > still experimental and investigative. It is currently

> > under " task

> > > > > review " in Chicago but according to the national office of

> BCBS

> > > Fed

> > > > > in Washington DC the DS is still on their E & I list.

> > > > >

> > > > > Surgeries can come off of this list w/o having a specific

CPT

> > > code.

> > > > >

> > > > > BCBC Fed told me they were only going to pay for

the " gastric

> > > > bypass "

> > > > > portion of my bill but when I got my statement from Dr

> > > 's

> > > > > office they had paid a portion of 43633 and 43847. I still

> have

> > > not

> > > > > been sent an EOB (explanation of benefits). I was told that

I

> > may

> > > > not

> > > > > receive this until the task review is complete.

> > > > >

> > > > > The DC office is very aware of this problem. If anyone is

> having

> > > > any

> > > > > problems with their local (state) office call the DC

office.

> I

> > > was

> > > > > told that my surgery was flat out denied by the Oregon Fed

> > office

> > > > > because it was E & I. Thanks to Judi in MS who got me in

touch

> w/

> > > the

> > > > > DC office.

> > > > >

> > > > > The name for our surgery that Dr is now using IS

> the

> > > > > DESCRIPTION of CPT code 43847. Dr Gagner IS correct in

saying

> > > that

> > > > > the DS surgery is not covered by BCBS Fed in NY. Do people

> still

> > > > get

> > > > > this surgery paid for? Yes. Sometimes it slips through with

> the

> > > CPT

> > > > > code 43847 which can also be used for a " Distal RNY "

surgery.

> > > Other

> > > > > times (like myself) we have to take it to DC or OPM to have

> > them

> > > > > handle it vs the local state office. I haven't heard of it

> ever

> > > > being

> > > > > denied completely.

> > > > >

> > > > > Let me know if I can provide further clarification. I feel

I

> > > could

> > > > > write a book on the subject!

> > > > >

> > > > >

> > > > >

> > > > > LAP DS Dr 1/23/01

> > > > > 268 BMI 42

> > > > > 182 BMI 28

[Guest guest]

> Dear Danine,

>

> It is very frustrating and scary to go

> through this process w/ Fed BCBS. The main thing you can do is

press

> for a " Pre-Authorization " not a " Pre-Cert " . They say that they

> stopped doing pre-auth in June of 2000 but they still do them.

;

Again, not all people are having similar experiences with Fed. Blue

Cross.

I tried to get mine pre-authorized by Federal Blue Cross in Oregon

and was told that

they would not do a pre-authorization on a procedure that does not

require one.

However, they reminded me to get the hospital portion (not the

procedure itself)

pre-certified.

How is it 2 different people can be using the same surgeon and the

exact same

insurance yet have such diverging responses from our shared insurance

company? Do

you think the fact that your surgery was in January and mine in July

might explain

it?

How might others get a pre-authorization if they are faced with the

statement I got?

gobo

[Guest guest]

Hi Gobo,

This is just an example of how screwed up they are!! I did not get a

pre-authorization for my 1/23 surgery (hence the denial of my claim

initially) but Montgomery DID for her 1/5 surgery with Dr Welker.

If a patient continues to press them they will either pre-authorize

it or deny it. Then the pre-op can take the denial to Wash DC prior

to the surgery. It just depends on the comfort level of the patient

and surgeon with BCBS Fed's policies.

Knowing what I know now I would do it all the same way. It was

incredibly stressful though for a couple of months not knowing FOR

SURE if they were going to pay or not.

How are you feeling btw? Are you still having the stomach pains? Take

care.

> > Dear Danine,

> >

> > It is very frustrating and scary to go

> > through this process w/ Fed BCBS. The main thing you can do is

> press

> > for a " Pre-Authorization " not a " Pre-Cert " . They say that they

> > stopped doing pre-auth in June of 2000 but they still do them.

>

> ;

> Again, not all people are having similar experiences with Fed. Blue

> Cross.

>

> I tried to get mine pre-authorized by Federal Blue Cross in Oregon

> and was told that

> they would not do a pre-authorization on a procedure that does not

> require one.

> However, they reminded me to get the hospital portion (not the

> procedure itself)

> pre-certified.

>

> How is it 2 different people can be using the same surgeon and the

> exact same

> insurance yet have such diverging responses from our shared

insurance

> company? Do

> you think the fact that your surgery was in January and mine in July

> might explain

> it?

>

> How might others get a pre-authorization if they are faced with the

> statement I got?

>

> gobo

[Guest guest]

Hi Gobo,

This is just an example of how screwed up they are!! I did not get a

pre-authorization for my 1/23 surgery (hence the denial of my claim

initially) but Montgomery DID for her 1/5 surgery with Dr Welker.

If a patient continues to press them they will either pre-authorize

it or deny it. Then the pre-op can take the denial to Wash DC prior

to the surgery. It just depends on the comfort level of the patient

and surgeon with BCBS Fed's policies.

Knowing what I know now I would do it all the same way. It was

incredibly stressful though for a couple of months not knowing FOR

SURE if they were going to pay or not.

How are you feeling btw? Are you still having the stomach pains? Take

care.

> > Dear Danine,

> >

> > It is very frustrating and scary to go

> > through this process w/ Fed BCBS. The main thing you can do is

> press

> > for a " Pre-Authorization " not a " Pre-Cert " . They say that they

> > stopped doing pre-auth in June of 2000 but they still do them.

>

> ;

> Again, not all people are having similar experiences with Fed. Blue

> Cross.

>

> I tried to get mine pre-authorized by Federal Blue Cross in Oregon

> and was told that

> they would not do a pre-authorization on a procedure that does not

> require one.

> However, they reminded me to get the hospital portion (not the

> procedure itself)

> pre-certified.

>

> How is it 2 different people can be using the same surgeon and the

> exact same

> insurance yet have such diverging responses from our shared

insurance

> company? Do

> you think the fact that your surgery was in January and mine in July

> might explain

> it?

>

> How might others get a pre-authorization if they are faced with the

> statement I got?

>

> gobo