UPDATE: (Federal BCBS) Policy included, please give advice.

Figured they would throw **** at me so here goes…

So I called for an update on my claim today for the DS. The rep was completely confused that they denied for not having over a 50 BMI. Regence BCBS is handling it since my surgeon is in SLC. So I think they are getting confused with their local BCBS policy and federal (which requires 40 bmi). I plan to smack them with a stick. It is total BS and they know it. What should my plan of attack be? I have never done anything like this before. As of right now I told her to double check with the nurse, make sure they have it right. If she calls me back and they hold firm with their decision how do I write this appeal letter out?

Here is my policy: (I meet all requirements below)

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 co-morbidities who has failed conservative treatment; eligible members must be age 18 or over.

 

 

Note: Here are some things to keep in mind about surgery for morbid obesity:

• Prior approval is required for outpatient surgery for morbid obesity.

• 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 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 )

− 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  

− 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

 

• 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 postoperative nutrition and exercise program

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

Definitely get up with Diana Cox for appeals.

I have BCBS Federal, Basic and thankfully had it done before they changed the criteria-such as 3 month medically supervised diet. I think you're already on target with them confusing themselves over their own criteria for the DS. What does your DS doctor's insurance guru say about it...the one who submitted the information to begin with? It took me one week to get approval, so it just may be in the coding with you...just guessing. Hope you get it squared away asap.

Thanks Eileen!

I just hopefully got the BMI thing nipped in the butt but now they are saying i didn't do my dietician supervized weightloss for 3 months. lol I just faxed them 4 months worth. Don't they have something better than lies.... like acutally reasons?

Their job is to look for loopholes so they can deny you. Hang tough and keep fighting!

Grrr! I know they are a royal pain in the ass but as Major Mom just said, they will do everything they can to deny you. If you have your PCP or doctor sign off saying you and he/she discussed diets (all types too)  and it is in your records then that is considered supervised dieting. That's what I used, even before it was a requirement with BCBS. You might want to try that if push comes to shove. Good luck!