Blue Cross/Blue Shield Federal - Help?

BCBS-FEP has new requirements as of 2011.  The definition of morbid obesity is the same - BMI of 35 or greater with 2 or more co-morbidities or greater than BMI of 40 with no co-morbidities.  But last year, there were no other requirements and the approval process was very fast.  This year's requirements:

Note: Here are some things to keep in mind about surgery for morbid obesity:
• Prior approval is required for outpatient surgery for morbid obesity. For more information about prior approval, please refer to page 17.
• Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the following pre-surgical requirements:
− Diagnosis of morbid obesity (as defined on page 52) 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 34 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 assessment of the member’s ability to understand and adhere to the pre- and post-operative program, performed by a psychiatrist, clinical psychologist, psychiatric social worker, or psychiatric nurse (see page 85 for our payment levels for mental health services)
− Patient has not smoked in the 6 months prior to surgery
− Patient has not been treated for substance abuse for 1 year prior to surgery

If you go to fepblue.org, this info is on pages 52-53 of the 2011 Service Benefit Plan.  I know it covers the band, RNY and VSG, not sure about DS.

Hey :-) I just wanted to know how your surgery went and what were the exact steps from beginning to end that you had to do under the new requirements with your insurance. Does it matter if you have all the required documentation but its a few months over a yr old like your medical necessity letter that was when it was submitted. Im starting my journey over and just want to know what to expect. How long was your approval process?

Hi there!

My surgery went well. It was very uneventful. I went in early Friday morning as the first case and was home by Sunday evening. The only pain I had was the first night, but it was pretty well controlled with the narcotics.

The approval process, from beginning to end, was less than 2 weeks.  I had to first, however, have a letter of medical necessity from my primary care physician, a clearance letter from my cardiologist, my clearance letter from the psychologist and my nutrition class out of the way before my surgeon's insurance coordinator would even submit to the insurance for approval.  Once BCBS received everything, however, it all went very quickly. I, myself, tried my best to move things along as quickly as I possibly could by booking back-to-back appointments with all these people so that I could get everything moving.

I wish you lots of luck (AND PATIENCE.....lol); you're in for quite a ride!

I am right behind you here, just starting out, fepblue. and border line on everything, 40 bmi and been keeping my #s at bay with diet. no sugar etc. but htis would be a dream come true! anyhow, I did more over 2 yrs ago, then i was kinda sick for 2 yrs, so i figure, these folks have all the procedures doctors medicines etc i have been through the last 5 yrs,,, what do they need? I can see this if you had "other insurance" anyhow gonna give it my best shot, Good luck

I know I'm just about a year late with my response, but I do see others with recent responses, so I'll jump right in :-)

I am currently awaiting approval for my surgery (which I am hoping to have on the 15th of February). I met all requirements, but I am waiting to hear from BCBS [Federal]. I found my way to this forum because I am wondering how long it will take. Unfortunately, I fall under the new [2011] requirements and it seems to take a little longer to hear something back from them. The letter by my PCP (which documents "medical necessity") includes information on a medically supervised weight loss program that I tried back in 2009, for approximately 3 months; I was unable to stay on the program longer because I was not able to tolerate the medications I was on.  Having said all this, I will sit and cross my fingers and await a response from my insurance and keep you all posted. Good luck, all!