BCBS FEP and the Sleeve

I got my denial letter today.  Super bummed, especially after I have been reading all over the place that Fed Blue Cross is one of the few that is approving the sleeve.  According to my denial:1.)My BMI does qualify me to recieve weight loss surgery 2.)VSG is not an approved procedure for weight loss because it does not produce "superior weight loss re****s" 3.) I am not able to submit and appeal or submit a review to the OPM 4.) I can resubmit a second review but must submit additional information that was not originally included with the 1st request for precertification.   If anyone has any helpful info for me or where I need to start, that would be wonderful!  My insurance coordinator from the surgery group basically told me I have to wait until Blue Cross officially begins paying for the Sleeve or choose another surgery.  I am not interested in any other surgery. 

Thanks!
Angel

That was the procedure I was going to have, however BCBS changed their approval procedure for the sleeve, you must have a BMI of 50+. Because I was not willing to put on any additional weight I chose the RNY after consulting my other options with my surgeon. I suggest you do the same. Good luck

I have Federal BCBS and also live in Virginia.  My second appeal was just denied and I am going to the OPM.  I am using the Lindstrom's over at ObesityLaw.com.  They have been wonderful.  I  have been approved for a revision to RNY or another band, but they are standing by that the VSG is investigational.  The reason that some get approved for the VSG with Federal BCBS is that their state administrator of their policy interpets the policy differently than our Virginia administrator does.  It is VERY frustrating.  I should know something by early October with my last appeal.

Mistakes like this happen all the time with Federal BCBS. It's because local insurance companies act as administrators and make mistakes. It's pretty straight forward and you can and should fight it. The qualification for WLS is a 35 BMI with comorbidities such as diabetes or a 40 BMI. There are no other qualifications such as a history of a high BMI or a 6 month supervised diet. The VSG is a covered procedure and has been since 2008. If your BMI is over 40 it will be easy for you to win, a little harder with 35.

Here's the benefit plan so you can go see the details:
http://www.fepblue.org/benefitplans/2010-sbp/bcbs-2010-RI71- 005.htm

Here are the details:
"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.  Benefits are also available for diagnostic studies and a psychological examination performed prior to the procedure to determine if the patient is a candidate for the procedure. Note: You must get prior approval for outpatient surgery for morbid obesity. Please refer to page 16 for more information."
See section 8 for information on appealing to the Office of Personnel Management. You can go ahead and do that right away. They'll send it back to your local administrator which will get some action. You're supposed to appeal through the local administrator first but you can always go direct to the OPM if you want to. Just call your local administrator back, if you got a denial letter it should have had information on how to appeal.

Someone is giving you bad information. Go ahead and fight for what you want. It's worth it. I'm still fighting but my case is a little more complicated - I had a revision. They told me recently that they agree VSG is covered and I qualify but that they needed more data on whether a VSG is appropriate for a revision. Basically I had to read dozens of studies and pull it all together for them, it'll be submitted next week.

You can look at my appeal blog in case anything I've written helps. I did one last letter that I'll post there in the next day or so.

http://vsgappeal.blogspot.com/2009/06/vertical-sleeve-gastre ctomies-no-longer.html

Fight, fight, fight! And if you lose fight some more after you self-pay. The VSG is great.