Federal BC BS

Anyone have Federal BC/BS and had plastic surgery after WLS? 

yes, I am having BR done on May 6th!  They didn't even require a pre-approval, only a medical necessity.  I had to explain that one to the dr. office. 

I had the same situation when i had my RNY years ago, I never had to have a pre-approval for that either.

Debbie

That's awesome!  Did the plastic surgeon submit the paperwork and the medical necessity for you or did the mn have to come from your family doc?

The plastic surgeon submitted everything, and then I waited 2 weeks.  I called BC BS to check on the status, and they told me on the phone that they didn't even have to submit anything!  There isn't a pre-approval process to go through!  So, I called back to the plastic surgeons office and told them all of this.  Once they verificed all of this with insurance, they called me back and set me up with a surgery date! 

Debbie

Wow Debbie that's AWESOME!!!  I sure hope that's how it works for me    I wonder if the type of plastic surgery makes a difference?  Can I ask what kind you had?   

I had RNY back in 2004, I will be 6 years out as of May 17th!  I am now having breast reduction w/o implants on May 6th.  BC BS told me specifically that preapproval wasn't needed for a breast reduction only that it be medically necessary, but they didn't require paperwork submitted prior. 

I have been going to the chiropractor every 7-10 days since Christmas for my back, so I figured I would have a problem argueing my case if they argued medical necessity!

Debbie

Wow, 6 years out is awesome!  Congratulations!!  Thanks for sharing your info and advice, I truly appreciate it.  Best wishes on your surgery!!

Martie,

Please be aware; no prior approval necessary means they are not allowed to  pre-review/approve the surgery.  A decision of Medical Necessity will be made after the procedure has been performed, and the documentation has been submitted.  There is specific criterion for br (I believe it's => 650 grams per breast reduction).  There are also similar specific criterion that needs to be met for a paniculectomy.  The Federal Employee Program adheres to national guidelines, which may vary from your state's plans policies.  ( Here is BCBS CA, which i beleive is very close to the Federal Program):  

paniculectomy;
http://www.anthem.com/ca/medicalpolicies/policies/mp_pw_a053 328.htm 
reduction mammoplasty;
http://www.anthem.com/ca/medicalpolicies/policies/mp_pw_a053 474.htm

I suggest you call the plan and request the Medical Policy Criterion and discuss them with your Pvd to make sure you are both comfortable you meet the criterion before you have the procedures.  I work for a BCBS plan on the FEP program, and have seen these denied because they did not meet the plan's definition of Medical Necessity.  You can appeal, but there's no guarentee.  Get all the info before, better safe than sorry.

oh, sorry, forgot;  Good luck!!  I hope i works out for you.

Thank you so much Bostonbabs for all the great information!!  Unless my insurance gives me approval before the surgery, I won't be scheduling anything for awhile.  I have 3 kids, 1 graduating from hs, 1 graduating from college and 1 already in college. They are my first priority