Question do you have Blue Cross Blue Shield Federal?

 

I was ready to get my revision surgery from the Sleeve to the DS.  I was told that my BMI must be 35 or more for the past 2 years in order for Blue Cross Blue Shield Federal to cover the surgery.  

My BMI was 34 back in 2012.  So, the office new patient rep said Dr. Stewart cannot do my surgery.  

 

Has this happened to any of you?  

Hello,

The same thing just  happened to a friend of mine who has BCBS Federal. She was denied a conversion from lap band to RNY because her BMI dropped below 35, she decided not to appeal and just wait another year.

However, it sounds to me that your surgeon's office hasn't even tried to get an approval. Am I right? If I am, then they should submit the request to BCBS and then if/when they deny you, a request to reconsider can be filed.

The BCBS Federal plan brochure is located here: 

http://www.fepblue.org/downloads/2013-service-benefit-plan-brochure_100512.pdf

I copied and pasted the info below from pages 59-60 and the appeals process is on page 125

 

 

"Gastric restrictive procedures, gastric malabsorptive procedures, and combination restrictive and malabsorptive procedures to treat morbid obesity – a condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with one or more co-morbidities; eligible members must be age 18 or over.

Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the pre-surgical requirements listed below.

The member must meet all requirements.

·       Diagnosis of morbid obesity (as defined on page 59) for a period of 2 years prior to surgery

·       Participation in a medically supervised weight loss program, including nutritional counseling, for at least 3 months prior to the date of surgery. (Note: Benefits are not available for commercial weight loss programs; see page 38 for our coverage of nutritional counseling services.)

·       Pre-operative nutritional assessment and nutritional counseling about pre- and post-operative nutrition, eating, and exercise

·       Evidence that attempts at weight loss in the 1 year period prior to surgery have been ineffective

·       Psychological clearance of the member’s ability to understand and adhere to the pre- and post-operative program, based on a psychological assessment performed by a licensed professional mental health practitioner (see page 90 for our payment levels for mental health services)

·       Member has not smoked in the 6 months prior to surgery

·       Member has not been treated for substance abuse for 1 year prior to surgery and there is no evidence of substance abuse during the 1-year period prior to surgery

 

Benefits for subsequent surgery for morbid obesity, performed on an inpatient or outpatient basis, are subject to the following additional pre-surgical requirements:

·       All criteria listed above for the initial procedure must be met again

·       Previous surgery for morbid obesity was at least 2 years prior to repeat procedure

·       Weight loss from the initial procedure was less than 50% of the member’s excess body weight at the time of the initial procedure

·       Member complied with previously prescribed post-operative nutrition and exercise program

·       Claims for the surgical treatment of morbid obesity must include documentation from the member’s provider(s) that all pre-surgical requirements have been met. "

I am in the process of getting approval for lap band to sleeve with BCBS Federal. I am concerned about this requirement:

Weight loss from the initial procedure was less than 50% of the member's excess body weight at the time of the initial procedure

I did lose to goal weight with the initial surgery 10 years ago.

I have completed all my required appointments and now I am waiting for my three month weight tracking. My MD office has my weight recorded for three months but failed to put the obesity code in the diagnosis so I had to start over with the three months.

Good luck!

Hello!

wondering if you got the revision approved with BCBS Fed of TX or not!!!

I was denied!!!

Very frustrated at the moment!!!

Wondering what you had to all do or say to get it approved!

Thanks!

Hey Babygirl!

Remember that even if you have the DS, you will STILL have to get your diet in order . . . that means you'll need to drop the carbs STILL!  the magic is that you will have to stop putting certain things in your body and you will have to stop eating as much as you like and when you want to.  We have to learn to be mindful and stop the instant gratification with food.  It is real baby like and we are not babies.  We need to eat for nourishment.

I haven't had a gain but I never lost to goal.  No doubt that I can still lose and I have no doubt that you can too.  Do you want to give it a whirl together?  I am going to start the 5 Day pouch on Sunday or Monday - more than likely Sunday.  Are you interested?  We can use the Grads Forum for posting and text back and forth. 

Check out the 5 Day pouch.  I have the books so if I find anything particularly insiteful I will post about it.  The books are really good by the way.

 

All Best,

Layla

 

Hi Zee Starrlite,

I really need something more than just restriction.  I am going to pass on the 5 day pouch.  I appreciate your input and concern.

Best wishes to you!

The 5 day pouch test is really about ditching carbs and getting back to WLS POST-OP basics - protein first, 30/30 drinking rule, lots of water, no snacking, and daily exercise.  In the Interim because of the mindfulness you can feel your sleeve/pouch again.  Kaye's books  Actually awesome.  She's no simpleton.

 

I hope you be able to have the DS.  It's a great surgery when you can follow the guidelines.

Best

 

 

I know exactly what you are saying.  I already know myself.  I need more than restriction.  I appreciate your concern and I your honesty.  I don't know if I will be approved for the DS.  

If not then I have no choice but to be stuck with the VSG, I might consider to do the 5 day pouch test.  I hope I can rely on you to be there for me.  

 

Thanks so much Zee!  Best wishes to you 2!!!

Call BCBS

http://medicalpolicy.hcsc.net/medicalpolicy/home?corpEntCd=T X1&path=/templatedata/medpolicies/POLICY/data/SURGERY/SUR716 .003_2012-02-01&ctype=POLICY&cat=Surgery#hlink