Question:
Hi, I have a BMI of 41 with no known co-morb's and I have BCBS PPO--does anyone know
the criteria they use to determine medical necessity? I have sent my pysch eval, PCP letter, a personal statement, along with letters from my family and friends. Think this is enough? Thanks for your help. — TP (posted on May 21, 2002)
May 20, 2002
Read my profile---your answer is there
— Linda L.
May 20, 2002
You really need to call BCBS about your policy. It depends on what policy
your employer chose. This determines if they cover WLS and what the
requirements are. I have BCBS and the policy my employer has covers WLS, so
I was approved the first time. Many times people blame the insurance
company, when it starts with the employer.
— Cheryl S.
May 20, 2002
Weight loss is a covered benefit on my plan too---but I have been fighting
since Nov to be approved--
— Linda L.
May 21, 2002
I had surgery a little over 3 weeks ago and I have BC/BS PPO
I was 100lbs overweight w/ a BMI of 38. I was given authorization over the
phone. My card has a website http://www.fepblue.org this is where it gives
what is covered.
— Michell C.
May 21, 2002
Your profile is not available so there is very little anyone can
tell you from this question. It depends on where you live, the type
of policy you have and who your employer is... for starters... I have
Federal
and shouldn't have any problem (waiting now) but others have trouble
with other types of BC/BS. As to co morbids... no pain in your back, legs,
hips, knees or feet? Those can be part of your overall package..
sometimes
we forget they are co morbids.
— Lisa C.
May 23, 2002
No,I think you need more documentation. Consider evaluating your health
more closely for possible co-morbid conditions. Examine every possible
symptom for obesity association. Chances are, you do have some related
conditions which may ensure approval for WLS. Best wishes.
— ERICK B.
May 23, 2002
I had Blue Cross/Blue Shield PPO and it was denied. My BMI was 59, I was
borderline diabetic and had two knee surgeries from the pressure of the
weight and still they denied me. Didn't matter if it was "medically
necessary" because weight loss surgery was specifically excluded from
the policy. No exceptions. So the best thing to do is call your carrier
or get a copy of the group contract and ask if weight loss surgery is
covered. I ended up switching my insurance to Aetna who approved me within
1 day of my first request. Good luck.
— Diananana
May 23, 2002
I also have BCBS PPO of Georgia. I requested approval in February and was
approved in about a month. My surgery was May 20, 2002. They initially
said no but my doctor wrote a letter and son did I. My BMI was 43 and my
co-morb's were high blood pressure, shortness of breath (all overweight
people have this) and being just plain fat. It is now May 23rd. I am four
days post-op and so far so good.
BCBS gave my doctor a pre-cert for the hospital date, even though they
denied some fo my pre-op tests. They never told me I was approved but they
gave a pre-cert. My doctor's said it was permission to do the surgery.
They have been paying my bills now.
Don't give up. Good Luck!
— Quin H.
August 1, 2003
I had Bc/Bs PPO of ALabama and they approved me with my BMI, one letter
from a Weightloss clinic, and it took two weeks.
— tia S.
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