BCBS/IL as a State Farm employee
My husband and I work at State Farm, but have chosen to use BCBS/IL for Health Insurance.
I had RNY in 2005 and need a revision surgery to a DS. I finally talked to someone at BCBS/IL who actually seemed to know what was going on. This is what I found out.
* State Farm considers the DS procedure to be "investigational"
* State Farm's contract with BCBS/IL no longer covers any gastric bypass surgery.
* For any bariatric surgery your surgeon/doctor will need to submit a "Predetermination of Benefit" for baratric surgery. This includes:
- a Letter of Medical Necessity
- surgical code for DS: 43645.....Roux-en-y: 43644.....Lap Band: 43770
- office notes/doctor visit documentation
- Procedure of Reports
- Health History Form
- since this will be a fight for coverage, i would include all dieting history, documentation of proof that it is a bonafide successful procedure, anything to prove your case
* This is to be sent to the Medical Review Board where it will take up to 30 days for them to get back to you.
* They WILL DENY this request (since it is not covered)
* You have 180 days to appeal this decision
* You can appeal by calling them or writing to them
* The appeal can take up to 30 days
So it will take 2+ months and one definite denial to see if they will cover the surgery (regardless if it is a first time surgery or a revision due to a complication).
The thing that gets me is that they cover the doctors who specialize in doing this surgery but not the surgery....
This phone conversation took place on June 2, 2009.
If anyone has BCBS/IL as a State Farm employee...i would appreciate hearing your experience (what surgery you had first timer/revision, if you had to appeal, when you did this, etc).
I had RNY in 2005 and need a revision surgery to a DS. I finally talked to someone at BCBS/IL who actually seemed to know what was going on. This is what I found out.
* State Farm considers the DS procedure to be "investigational"
* State Farm's contract with BCBS/IL no longer covers any gastric bypass surgery.
* For any bariatric surgery your surgeon/doctor will need to submit a "Predetermination of Benefit" for baratric surgery. This includes:
- a Letter of Medical Necessity
- surgical code for DS: 43645.....Roux-en-y: 43644.....Lap Band: 43770
- office notes/doctor visit documentation
- Procedure of Reports
- Health History Form
- since this will be a fight for coverage, i would include all dieting history, documentation of proof that it is a bonafide successful procedure, anything to prove your case
* This is to be sent to the Medical Review Board where it will take up to 30 days for them to get back to you.
* They WILL DENY this request (since it is not covered)
* You have 180 days to appeal this decision
* You can appeal by calling them or writing to them
* The appeal can take up to 30 days
So it will take 2+ months and one definite denial to see if they will cover the surgery (regardless if it is a first time surgery or a revision due to a complication).
The thing that gets me is that they cover the doctors who specialize in doing this surgery but not the surgery....
This phone conversation took place on June 2, 2009.
If anyone has BCBS/IL as a State Farm employee...i would appreciate hearing your experience (what surgery you had first timer/revision, if you had to appeal, when you did this, etc).
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