Question:
Anyone else Appealing BCBS denial?

I am in a downward spiral, and not sure how to proceed. My insurance company, Blue Cross Blue Shield keeps denying my claim. I worked for 18 months towards having bariatric surgery, had all the tests, was monitored for six months, visited the nutritionist, went on a liqued protien diet and lost some weight. Because one of my tests came back as having a compromised esophogus, my surgeon suggested I have the proedure known as "the sleeve" for VSG surgery. The insurance person at the doctor's office told me that BCBS told her that they do not do preapprovals for federal employees, that I should go ahead with the surgery and it would be approved afterwards. I thought that was strange, so I called them up and got the same answer. So we proceeded as instructed. Now, more than six months out, I am having to appeal their decision to deny. I know I shouldn't, and this is not the only stress on me, but I have gained back 15 pounds and have absolutely no control over my eating, have not been exercising nor drinking the 80 ounces of water. I think my diabetes has come back. I am terribly depressed and I feel like a total loser. I need to know if anyone else here is in the same or similar situation with BCBS. I suspect this might be happening to more than just myself. Thanks for listening to me.    — cydthekid50 (posted on July 18, 2009)

July 19, 2009
I am a Retired Postal Worker getting ready to have the gastric bypass procedure and have the Federal BCBS insurance. The information that BCBS gave to my physician was that it is a covered procedure as long as the BMI is 40 or above or a BMI of 35 or more with co-morbidities who has failed conservative treatment. The only preapproval listed is for an outpatient procedure. This is on page 52 of the 2009 Benefit Plan brochure also. Do you have the Standard benefit?? Or the Basic Benefit?? We the procedure done this year?? Or was it done last year?? I don't have the 2008 Plan Brochure to check to see if there's a difference in coverage between last year and this year. I can tell you that one of my friends who is still employed at the Postal Service with Federal BCBS had the procedure done in April and insurance paid for it. Her BMI was 46, if I'm not mistaken. Keep fighting. It's a covered procedure according to the Plan Brochure.
   — Mountain Mama

July 19, 2009
Keep going through the appeals process. Eventually OPM will get involved - you just have to exhaust the internal process. Here's a link for the process: http://www.opm.gov/insure/health/planinfo/consumers/disputes.asp The federal contract SHOULD supersede each state's medical policy, but that doesn't always seem to happen. Best of luck to you!
   — Privacy Please

July 19, 2009
The procedure was done September of 2008. I have Basic BCBS coverage. BCBS is telling me that the VSG procedure is still an experimental procedure, and therefore is not covered. The 2008 brochure is online at FEP Blue.
   — cydthekid50

January 10, 2010
Finally! OPM stepped in and everything has been paid! Whew!
   — cydthekid50