Bad News on Appeal. Now What?

Let us know how it turns out...I am thinking that whomever wrote the policy for your company left out the 40 BMI is auto approval...now if that was on purpose or a complete error...who knows...it just goes against EVERY other medical policy I have ever read.  They all  seem to be 35 with two comorbids or 40 and you get it for just being 40 BMI...DO NOT GIVE UP...they ought to cover it...

Chin up and keep fighting the dragons...

 Ok, I have been calling RRD HR and BCBSIL asking these same questions.  Why is 40+BMI line left out?  There's only 35BMI  w/2 comorbids.  I can not figure out why that one line was omitted?? Surely 40+ MORBID obesity is reason enough to approve surgery. And what's worse no one on either end can clarify that reasoning to me.  I am starting the process of completing the other requirements and the surgeons requirements.  I have BMI of 43 and I don't want to be denied because an error of omission.   It's frustrating because as per BCBSIL policy (whi*****ludes the 40 BMI language)  it also states  

"If there is a discrepancy between a Medical Policy and a member's benefit plan or contract, the benefit plan or contract will govern."

Of course the RRD benefit plan will govern because of it's evasive language it will probably become an easier route to deny the procedure.  I also noticed that while BCBSIL policy was updated in July, RRD policy remains unchanged.  PLEASE let me know if you get approved at any point because I am starting the same path.

THANKS,
Hannah

Sorry I know I'm ranting a bit but here's one more thought.  As per the BCBSIL medical policy 40+ BMI is a DEFINITION AND DIAGNOSIS  of Morbid Obesity.  Can RRD contract actually legally determine that 40+ BMI is NEITHER a definition NOR a diagnosis for morbid obesity???  or is being morbidly obese not morbid enough for surgery consideration?

BCBSIL Medical Policy:

  A diagnosis of morbid obesity, defined as:

• Body mass index (BMI) of greater than or equal to 40 kg/meter squared; OR
• BMI greater than or equal to 35kg/meters squared with at least two (2) of the following co-morbid conditions which have not responded to maximum medical management and which are generally expected to be reversed or improved by bariatric treatment:
  • Hypertension,
  • Dyslipidemia,
  • Diabetes Mellitus,
  • Coronary heart disease,
  • Sleep apnea.