BC/BS Federal
Running into some problems with BC/BS Federal definition of 'medical necessity'. I meet the criteria in the benefit book but according to new info I might not qualify . Something about 2 or more treated and uncontrolled comorbidities - is this the standard now?
http://www.fepblue.org/benefitplans/2012-sbp/bcbs-2012-RI71- 005.pdf
pages 53-54
link is above for their policy
i am looking at FEP BCBS 2012 as i type this and it looks like nothing has changed since 2011. they have the same requirements. if you meet all their listed requirements and have a doctor write you a letter that this is a 'medicaly necessity' then the surgery should be a breeze to cover.
FEP BCBS approved my surgery in dec 2011 and i was a light weight with no comobidites. i just followed their guidelines and got my doctors to do the rest. its a long long process but just stay organized and get your duckies in a row and it should be easy:) good luck
320/170/150
SW/CW/GW
from what i have found the guidelines do not apply to state guidelines. fepbcbs has their own set of guidelines, requirements, coverages, ect.
when applying for approval they did try to follow the guidelines of utah state which is regence bcbs. i contacted them and told them to stop appliing me to the state insurance and only to federal. this solved my issues when they got confussed.
i did not meet the requirements to have surgery in utah (regence bcbs) but since i federal these did not apply to me, hence i was covered under a different set of requirements (which i met all the requirements)
I just received my approval from BCBS, after several appeals. However, mine is a revision, from VSG to DS. BCBS has really tightened up on their requirements for revisions. But not so much for their initial procedures.
I wouldn't read too much into the "uncontrolled" comorbidities. Your surgeon's office will know what documentation is required for BCBS. Good luck!
Donna