BC/BS Federal

Taking advice and seeing if anyone has any experience with BC/BS Federal 2012 restrictions:
      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?

I don't think anyone can advise you with what you have provided thus far - the "new info" is too vague. My guess is that the info in an up to date benefit book is the right answer, but I really don't know.

Larra

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

 

Thanks Danni - you are right - that's exactly what I read thinking I would meet the criteria. The 'uncontrolled' came over the phone from Travis in Dr. Stewarts Dallas office. I haven't had an appointment yet, and have only discussed over the phone. But this doesn't sound right, think I'll try to schedule an appointment to see if I can get approved - at least try to get the process started. Thanks for the encouragement!

I have FEP BCBS and my comorbities are mostly controlled, but so far they have approved and paid for all of my pre-op testing, EGD etc. for the DS. Sure hope I don't have any surprises!

BCBS Fed follows the BCBS state you are in. Check those guidelines. They will be what you have to adhere to.

What if the state affilliate BC/BS has a total exclusion on all WLS, and does not even let employers have a choice to cover wls, as is the case with BC/BS of Kansas?  That would exclude the federal employee or dependant from what is normally covered under Federal BC/BS?

Little late responding, but it was my understanding that BCBS Fed follows the guideline of whatever state you are going to have surgery in. For example, if I was in AZ, and wanted to have surgery in CA, and had BCBS fed, I would have to follow BCBS guidelines in AZ. I have no personal experience, but had a friend that got hung up on the state guidelines, even though she had fed which said it would cover pretty much everything.

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 hae BCBS Federal Employees Plan. The benefits are not established at the state level, but rather are the same for all federal employees regardless of where they live.

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