Question:
BCBS Denied
BCBS Policy is OBESITY MANAGEMENT EXCLUDE(S): Obesity. Care and treatment of obesity, weight loss or dietary control whether or not it is, in any case, a part of the treatment plan for another Sickness. However, treatment for Morbid Obesity will be covered under this Plan when necessitated as the result of a specifically identifiable condition of disease etiology. They are telling me that they only cover this surgery if morbid obesity was CAUSED by a medical condition. Has anyone ever seen a policy like this? I'm wondering if I should handle the first appeal myself or go straight to Walter Lindstrom. It seems BCBS policy on this is unreasonable. Susan — SJP (posted on March 5, 2003)
March 5, 2003
Is your BCBS a PPO? I just saw my surgeon for the first time... he thinks
I will be approved easily. The letter I got from BCBS PPO of Florida asked
for the diagnosis code, the treatment code, and statements of medical
necessity... I hope they will cover it!
— Tim W.
March 5, 2003
Susan, I looked at your profile and I do not see any co-morbs listed. Do
you not have anything - GERD, osteoarthritis, joint pain, depression, sleep
apnea, asthma, high blood pressure (even slightly elevated), diabetes, etc.
etc.?
<p>You technically meet the NIH criteria of over 40 BMI with no
co-morbs but in BCBS's case they want some other conditions that are being
created or aggrivated by the morbid obesity. This is exactly how my BCBS
policy reads. I was a 64 BMI with life long diet history (but not that
many diets, about 5 tries spread out over 23 years - 4 in the last 8 years)
and at the time I started the process not too bad of co-morbs. My surgeon
put down GERD (which in my case was pretty non-existent with mediation,
essential hypertension (which I had not been treated for because it was
never consistently high) and osteoarthritis of my knees, degenerative joint
diseas in my low back and joint and hip pain. As part of the process I had
to have a new sleep study which ended up showing I have moderate to sever
sleep apnea. I more than qualified before that diagnosis but I'm sure that
sealed it.
<p>Who sent the letter? What did it have in it? A case needs to be
built as to why you qualify for this surgery and what disease etioogy is
factoring in here. It's not that the disease is causing to gain weight
it's that the MO condition is creating these other medical conditions.
That's what they mean by disease etiology. Before you apeal you need to
see exactly what was sent. I have BCBS of WI and they require a psych eval
and detailed diet history. Were they included? Even if they are not
required they are not going to hurt your case. You need to make sure when
that appeal goes in that everything in your medical history is addressed
and how this affecting your health and life etc. If you have even one or
two good co-morbs I would think you should be able to get this covered but
it will likely take persistence.
<p>One more thing. If this is going to be an official appeal and go
before the appeal board you have the right to be there and present your
case. Don't let them tell you, that you can't be there - cause it's bull.
This may be your best chance because who better to talk about you and your
life but you. It's how I won payment of chiropractor bills on a 3rd board
appeal. They denied me access to the board the first two times and were
forced to do a 3rd one, that when I got to present my case and the whole
picture it was all paid. Took 3 years but it was worth it to me. If this
is just going back to medical review then I would just ask to have this
additional information reviewed for possible approval of surgery and
reserve the official appeal if you really need it. Good Luck! BCBS can be
tamed!
— zoedogcbr
March 5, 2003
Hi, BCBS doesn't seem to care about co-morb issues. They are saying they
want me to have a disease that CAUSED the weight gain. IS there such a
thing? I did have a major episode (clinical diagnosis) of depression...
this is where most of my weight game came from.. the actual depression as
well as the medication I was given. I wonder if this could be considered a
"disease"?
I am in the process of writing an appeal letter. I think I'll cc Walter
Lindstrom and see if that makes a difference. If it doesn't... then I
guess I'll have to hire him.
thanks
— SJP
March 5, 2003
I have BCBS ppo (ohio). I was approved in three weeks with my co morbs
beign DEPRESSION, feet pain (was seeking PT for this), general aches (knee,
hip), insomnia, acid reflux, etc. I'd definitely list the depression. My Dr
told me if I was treated for a hangnail I sould document it and turn it in.
ANYTHING. Have you been to ER? Get that documentation too. Along with the
mental health info. DON'T GIVE UP! God Bless. Jamie
— Jamie M.
March 5, 2003
Tim, my BCBS is a PPO but I think every insurance is different...depending
on what your employer purchases..etc.
— SJP
March 5, 2003
I think BCBS is trying to make some changes must be getting a lot of
flak.My policy has a written exclusion but yt the other day I get a letter
asking for more info so my surgeon is sending me to my PCP for a H&P
and I need 5 years medically supervised diets and a letter of medical
necessity the Drs offce also suggested I write a letter on my behalf which
I have done and Im going to include pics of myself. And the clincher is Im
trying to get Lap Band for which they are KNOWN for denying so anythings
possible with them right now.
— Lisa F.
March 5, 2003
"when necessitated as the result of a specifically identifiable
condition of disease etiology".
<p>Susan did they tell you it has to be the disease causing the MO or
is that your interpretation? This is a chicken and egg thing and which
comes first. I know from working with them that they are looking at which
conditions are being exacerbated by your MO and would likely go away or
improve and which diseases are not allowing your to exercise etc. Having a
joint pain and/or osteoarthritis is a disease that can cause you not to be
able to exercise therefore it is logical you would have difficulty losing
weight. However, being overweight is likley causing the joint issues. So
you can split this hair either way. The bottom line is they want to know
what diseases you have that are part of this overall situation and would
likely improve with WLS. Depression can cause weight gain and lack of
exrcise and depending on it's origination may be helped by losing weight.
— zoedogcbr
March 5, 2003
Chris, it wasn't just how I read the policy. It is what BCBS told me as
well as my surgeons office. We (surgeon and I) think the whole thing is
flaky.
— SJP
March 5, 2003
I would still put together any additional info and file an appeal or
whatever you want to call it. I think the person telling your this is not
totally clear on what the intention of that statement means. I only work
with the director of customer service anymore - no customer service people.
My connection then works directly with medical review to get the straight
scoop. The reality is I believe you can make any co-morb be a significant
cause of your MO or a signigicant contributor. It's just the spin you put
on it. At this point I wouldn't waste my time and money with Walter
Lindstrom. Go to the appeal board yourself and be very very prepared to
present your case as unemotionally as possible. Just the facts! Good
Luck!
— zoedogcbr
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