XPOST: Calling all Federal BCBS lightweights for DS!

Hi all!

I turned my information into my insurance a week ago and called today for status. The rep told me the nurses denied me for a BMI less than 50. The rep and I both agreed that made no sense since the policy states only a 40+ BMI or 35+ w/comobidities. I asked her if the nurse was refereeing to Regence BCBS or Federal BCBS, Regence has the 50+ BMI guideline. So my rep (who is totally nice and awesome) said she would talk to the nurse and get this straightened out. If the nurse doesn’t change view point, I will have to come up with a good appeal letter. Does anyone have one for rough draft use? Also take a peek at the policy below.

 

Only reason I am stressing is because my surgeon wants this done so I can have surgery in December! Wow so soon! So trying to get through all the bumps quickly.

 

Here is my policy: (I meet all requirements below)

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.

 

 

Note: Here are some things to keep in mind about surgery for morbid obesity:

• Prior approval is required for outpatient surgery for morbid obesity.

• 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 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 )

− 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  

− 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

Yep, it sounds like they got their policies confused. Keep talking to that rep and maybe your case worker at your surgeon's office. Keep us posted.

--gina

Thanks Gina:)
I will keep you all informed. I think its kinda funny they want to deny for this... out of all reasons...one that isn't even in policy lol

Well, as you pointed out, they use the 50BMI on all their non federal policies. It's a load of crap.

The LWs I know that have federal BCBS didn't have any issues getting their DS approved.

Some of their policies also say you have to have a BMI of 50 to get a sleeve which is just crazy!

Actually I just got through reading the policy on the sleeve. Just like you said! OMG a sleeve ... you have to have 50+ BMI lol oh insurance agencies are just a blast

Just got word that now they are trying to deny me for not doing my 3 months of provider/dietician. I actually did 4 months of it lol So I had my dietician fax the info again to them. My insurance guru said they are out to get me  What did i ever do to them?! At least I have an awesome insurance rep and good surgeons office insurance guru. Battle battle!

They just don't want to pay for it...it's not you personally....

Keep plugging along.

Ammo:
1) use the NASID issue (I got the DS because I HAD to be able to take NSAIDS),
2) the fact that the RNY has a known issue of Reactive Hypoglycemia (see my blog entries of May 20th and 26th for the articles backing that up.
3) that another government agency covers the DS for anyone who is a 35 with or 40 without and that is MEDICARE!!!

Keep aiming at them, they'll give in eventually.

Thank you:) Great advice. Its hard not to feel hurt by them but I know its all about the money. I just hate I am on this tiny timeline, I fee rushed and stressed.

I could use the NASID ammo for sure my family runs with arthritus.