Revision from band to RNY- DENIED Federal BCBS

I have federal BCBS and have jumped through all of the hoops that they have required as part of the new critieria for 2011.  I have literally gone through the requirements listed in the benefits book and have met every single requirement. My BMI is currently 40.3 at the time my paperwork was submitted.  Today I called to check on the status of my pre-auth and was told that it was denied!!!  I am furious!! The agent on the phone stated that my request was deemed "not medically necessary".  I find that very funny being that I have a BMI over 40 and I have fulfilled every one of the requirements outlined in the benefits manuel.  Does anyone have any experience with this and if so what did you do? What are my options?  Does filing a complaint with the OPM help? I am very discouraged and any advice is helpful! Thanks.

Let me guess.....It's not medically necessary because the band did not " Surgically fail " you ?

Do your benefits say that you are only eligible for ONE WLS per members lifetime ? That's what mine said and I'm switching ins today during open enrollment so that my DD and myself can revise to the sleeve.

 My mother works for a health insurance company and said alway appeal... and if it's denied again appeal again.  She said never take no for an answer.  

Thanks for the replies!  Yes, Federal BCBS is saying that its not "medically necessary" and that the questionaire that I filled out on my first consultation (back in September 2010) states that I did not indicate that I had GERD (Acid reflux) and the paperwork submitted by my surgeon is saying I do (which I do have and take over the counter medication for)  so BCBS is saying my information is inconsistant.  They do also cover revisions if you meet certain requirements which I have also met.  Regardless of whether I have GERD or not, I still meet the requirements.  I have a BMI over 40 and I have jumped through all of their pre-approval hoops!!! I will certainly appeal! Wish me luck! 

Has anyone had any other experience with being denied when they have meet all of the requirements? It just doesn't make sense that if you meet the criteria and have done all of the pre-approval requirements, then how can they deny you?

Below is the list of requirements for 2011 that Federal BCBS has put into place:

• Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the following pre-surgical requirements: − Diagnosis of morbid obesity (as defined on page 52) for a period of 2 years prior to surgery − Participation in a medically supervised weight loss program, including nutritional counseling, for at least 3 months prior to the date of surgery. (Note: Benefits are not available for commercial weight loss programs; see page 34 for our coverage of nutritional counseling services.) − Pre-operative nutritional assessment and nutritional counseling about pre- and post-operative nutrition, eating, and exercise − Evidence that attempts at weight loss in the 1 year period prior to surgery have been ineffective − Psychological assessment of the member’s ability to understand and adhere to the pre- and post-operative program, performed by a psychiatrist, clinical psychologist, psychiatric social worker, or psychiatric nurse (see page 85 for our payment levels for mental health services) − Patient has not smoked in the 6 months prior to surgery − Patient has not been treated for substance abuse for 1 year prior to surgery • Benefits for subsequent surgery for morbid obesity, performed on an inpatient or outpatient basis, are subject to the following additional pre-surgical requirements: − All criteria listed above for the initial procedure must be met again − Previous surgery for morbid obesity was at least 2 years prior to repeat procedure − Weight loss from the initial procedure was less than 50% of the member’s excess body weight at the time of the initial procedure − Member complied with previously prescribed postoperative nutrition and exercise program • Claims for the surgical treatment of morbid obesity must include documentation from the patient’s provider(s) that all pre-surgical requirements have been met

Why?  You're kidding, right?

Because they can.  Because there is no penalty involved in improperly denying you, and 95% of people who are denied will not bother to appeal - hence, they win.  Appeal, and if they deny you all the way up, demand external medical review.

And please, check out the DS as your revision surgery, so you have less of a chance of ending up needing yet another revision in a few years.

I also have the same Insurance of Texas. My Dr.s office submitted the pre-auth and I was denied due to not being medically necessary, so we appealed this a second time and once again refused. So I said heck with this. Then four months later I developed a problem and had the UGI done and it came back no so good. My esophagus was so large that all my fill had to be removed. It developed a long narrowing problem that I had for months but had no real symptoms of being tight like in the past. I would eat and throw up and then I could eat and all seemed fine, well when I wasn't throwing up the food still did not pass through it just sat and built up over time. end result damage to the esophagus. This was my third event of the same type. Well I am told that I have what is called Mechanical failure of the band, that I will never be able to have any fill and I also have a nice hiatal hernia that was diagnosed a year ago but I found out about this just recently.  My band is completely un filled, I am on liquids and then mushy foods for a few more weeks. When I swallow I am hit with a gurggling in my throat and then today I developed reflux. BC/BS Federal was not the company that paid for my Lap Band, so this is the first time with this one. I was told that there is no limit on how many revisions you can have. For if it is a medical emergency they cannot refuse you. If you read your handbook like I have close to the front of it, there is a section that states if your refused more than once. Contact OPM in writing and send all your informations to them, everything pertaining to your situation, then write a letter on your behalf about what you go through, how it has given you a poor quality of life etc. In the end according to the manual OPM will have the final say and if their team of medical experts feel that you need the surgery then you will have your surgery. I was otl the criteria is being obese two years, supervised diet 6 months and a new list of all your medications why your taking them and co-morbids and the BMI, your Dr. will need to document all of these as in the past. No one put in the first and second pre-auth my complications and what was put in there was reason for revision surgery was for poor weight loss and I was told I did not meet that criteria, but I did meet it due to the complications I now have. I am waiting to see the out come, approval or denial.

Unfortunately, I had to delete this post due to privacy concerns.

I have BCBS federal, administered by Carefirst. They are very bad about approving these surgeries. You might save time if the doctor just corrects the discrepancy and resubmits the packet. That may obviate the need for an appeal.

If you get denied again and need to do an appeal, be sure you get the exact grounds in writing. I put some of my appeal content on my blog, but it's not really relevant to your situation.