Q about BCBS FEP (Federal Employee Program)

Hello, I am looking into RNY surgery and my insurance is BCBS FEP Federal Employee Program.  I had read on OH that I should call and request the specific requirements for coverage from them, but when I did they just referred me to my 07 service benefit plan.  I checked the page they indicated and all it says is "an individual with a BMI of 40 or more, or an individual with a BMI of 35 or more with co-morbidities who has failed conservative treatment."  I was hoping to find something more specific.  My BMI is 36 (hovers between 35 & 36 actually) and I am on meds for hypertension and I am being treated by my doctor for high cholesterol/triglycerides, although no meds yet.  I have some other weight related probs, such as lower back pain, occasional depression (medicated when needed, although not at the moment), stress incontinence, sleep problems, joint pain, etc.  I can't seem to find out if a diet is required before approval or if I have to have uncontrolled hypertension (my meds help this) or what.  Anyone have experience with them or know specificially what they require?? Any help is GREATLY appreciated... Thanks, Kim :-)

Kim, The Service Benefit Plan is really helpful isn't it?  NOT!!!!  Go on their website under "Health Care Providers" and find "Medical Policies" and look for "Surgery for Morbid Obesity."  There are three criteria for coverage of bariatric surgery.  With a BMI equal to or greater than 35 and less than 40 you've got to have 2 co-morbidities, you've got to have a five year history of morbid obesity supported by medical documentation and you've got to have a clinically supervised 6-month diet within 24 months prior to surgery.  I thought I was going to have surgery this month, but when my doctor's office called about pre-certification BCBS asked if I had done the 6-month diet.  So I joined Weigh****chers this week and see my PCP on Monday and hope I'll have surgery in August.  Good luck! Pam

Pam,      I was unable to find the criteria info on the Federal BCBS site.  Any additional info on how to find this info would be greatly appriciated.                                                                                        Thanks, Darla

Kim, I have BCBS FEP and my PCM told me that they don't generally worry about the comorbidities...I went ahead and had a sleep study to document OSA along with the high cholestoral and blood glucose levels.  When I called the insurance the person that I spoke with assured me that there was no preauthorization necessary for the procedure, only the hospital stay.  When I spoke with the surgeon's surgical coordinator, she also seemed to be confident that my case would be approved. Like you, I am hovering between a 35 and 36 BMI.  I would just make sure that you have one of the big three documented...OSA, hypertension or diabetes.  That should be enough to cover you and get you an approval over the phone.  I will let you know more as I continue through the process.  At this point I am waiting for my psych eval, then I can get the insurance approval process rolling. Kristine

Hi, I too have fed BCBS.  However, my BMI is 41.  I called BCBS 2 times and asked if there were specific requirements for the surgery that were not listed in the book, the first lady was wishy washy and noncomittal, the second lady however, told me that all I needed was a letter from a physcian stating my BMI and that surgery was medically necessary.   If lady number 2 is correct (and I hope she is ) you probably only need the same letter only including 2 comorbidities. Here is a word of advice I got from a Bariatric nurse, she told me do not go into your Dr. and tell them you're thinking about WLS, she said you go in and tell them that you have decided to have WLS and need their support.  Apparently, a firmer stance is more successful. Good luck, Josie