What doe this response from Blue Cross Blue Shield Mean?

Hi all, I just got off the phone with BCBS Federal Plan and the rep read the letter to me regarding the medical necessity letter Dr Nick sent in. Here is what she read me over the phone: I did ask her if this is the way they answer all letters for requests of WLS, and she said yes.  The letter stated that they do not make a pre-determination of benefits.  Just that the patient must have a BMI of 40+ with co-morbidities, they must be over 18 years of age and a pyhc exam may be necessary. With a history of prior WL attempts documented.  They will make a determination of benefits when the surgical and path reports are sent in.   What kind of a repsonse is that?  Will a surgeon do surgery with this kind of a response? Anyone have any idea?  Thanks in advance for your help! Barbara Brewer

I am not sure - did you call the surgeons' office to see if they can help you  Jo

THe doc needs to send in proof  your BMI  your Psyc eval from a counselor ....your Diet History and a list of your co-morbids......Seems that once you get those in you should be approved

That sounds like the inital weight loss surgery criteria - was this  specific to revision of  weightloss surgery ??  Previous weightloss  -  looking for at least 6 months of medically supervised dieting -  that means regular visits to Dr  with chart notes  --- Your  chart notes from initial surgery  should sufice !  Make sure your Surgeon has a copy of the original file --- keeps everyone up to date !  Your surgeon  needs to send a letter and chart notes - high bloodpressure , sleep apnea etc...  chart notes  showing weight regain.  anything worth having is going to be somewhat of a fight  -  put on your boxing gloves !!!  just going to take some time ..

OK... They need to be much more specific than that. Have you checked out what the plan says in your booklet? If there is no booklet then online? Language is EVERYTHING. GET IT IN WRITING. Write a letter to them asking specific questions. Get a name for a person in the med. review dept. and send it to them certified mail. Make them answer your questions in writing regarding your revision. This is not the typical cookie cutter surgery. Be careful and good luck.

That is typical and infact my Dr had me get all the tests done and then submit it because of this kind of insurence issues. My mother has BC/BS and she is getting EGD done next month so she can get her approval for revision. I was approved for Lap over RNY then my EGD came back my pouch is way too small for that but my stoma is huge so I am now having to resubmit for DS. Most Dr's know insurence companies are tough and wont set a date until they know for sure.

I called and spoke with a rep about the BCBS FEB and authorization for revision.  Told that with explanation of co-morbidities and documentation and BMI where it currently is, there should be no problem with having procedure paid for.  But they won't precertify.

I cant answer your questions but the info they gave you is not exactly correct. I got this from the 2008 brochure . This is for BCBS Federal Basic. I have also included the link : http://www.fepblue.org/pdf/sbp2008.pdf Page 49 I think.

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.

Thank you for the information.   Barbara