BC/BS Federal

[atghr10 1]

Anyone have BC/BS Federal and had a BMI less than 40?

[Flippista 67]

Anyone have BC/BS Federal and had a BMI less than 40?

I started at 37.8 and went down to 35.4 BMI day of surgery.

[GassyGurl 428]

I had a bmi of 35.4 at my consult. BCBS said I couldn't drop below 35. In couldnt bear the thought of maintaining (not even able to lose 2 lbs) during the 3 months supervised diet, so I just went the self pay route. Plus, I wasn't fat enough in 2016. I was in 2013, 2014, 2015, 2017 but since I was a few lbs short in 2016, I probably would have been denied.

I may have been able to go through it all and appeal if needed, but I was ready to get the surgery Done.

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[atghr10 1]

16 hours ago, Flippista said:

I started at 37.8 and went down to 35.4 BMI day of surgery.

Did you have a comorbidity?

[Shelbel 7]

I have bcbc federal and was just denied. I have a bmi of 35.8 with comorbidities. They said the comorbidities that was submitted were considered controllable. Not sure what the difference between contollable and uncontrollable is but I guess I’ll find out during my appeal. I have several comorbidities but I’m unsure which the doctors office used. I’ll try to keep you updated on my appeals process.

[atghr10 1]

I have bcbc federal and was just denied. I have a bmi of 35.8 with comorbidities. They said the comorbidities that was submitted were considered controllable. Not sure what the difference between contollable and uncontrollable is but I guess I’ll find out during my appeal. I have several comorbidities but I’m unsure which the doctors office used. I’ll try to keep you updated on my appeals process.

Appeal, appeal, appeal

I had 3 co-morbidities and they are all
Controllable with meds, and cpap Machine. If you appeal someone else will look at it. Don’t give up!!

[barr3563 0]

I have been fighting with BCBS Fep for a year. I have appealed twice both were denied. My Doctor did a peer to peer review with a medical Dr. affiliated with BCBS and I found out today that was denied:( so frustrated!

[Shelbel 7]

Thank you for your support. My pcp wrote a letter and sent more of my chart to my surgeons office. They jad me write a letter explaining my medical issues, how I’ve tried to lose weight, and my family history. Hopefully this will work. They make it easy to get frustrated. I’m determined to get bcbs to pay for this surgery.

[AceBlaque 17]

Hello, I have BCBS as well. I had a sleeve gasterectomy in spring of 2015 and had no issues getting approved. In spring of 2017, my original surgeon and I saw that a full duodenal switch was needed for the absorption component so yhe process for approval began again...EGD, psychological evaluation, PCP visits and approval etc. Since BCBS only covered one bariatric procedure per lifetime, The situation with the second surgery is that it needed to be proven to be medically necessary and that I had been compliant with the sleeve gasterectomy in 2015. After the completion of my tests and visits, my package was submitted to my insurance company. As you guessed it, DENIED. I knew I had to act quickly since it was denied in the fall, this meant my deductibles has been met and in order to not have to pay them again in 2018, I needed to try to push for approval before 2017 ended. I knew that the appeal could take longer than I would need and after what decision I would be given, I would either have to have the surgery in 2018(deductible) or have to start the process from the beginning. Although I was frustrated about the denial, I decided to start doing what I knew to do, fight. You see I work for a medical insurance provider and advocate daily for members to receive the care that is needed, be it from physicians or the insurance company. I had assisted many members before in getting various approvals for different treatments that was needed to better their life. I went over all the things that I knew a review board and medical director would want to see/know before granting me a 2nd opportunity. Upon doing this I realized that my surgical team did not fit my needs this time around and to appeal the initial denial would be pointless since the evidence/tests needed for the insurance approval were not done by my original surgeon. I did additional research and found a surgeon in Texas that was well credentialed, accepted my insurance and also did initial appointments by phone since I was a patient from another state. After reviewing ALL of my medical history that was sent to him and discussing the prior denial, we forged forward. After phone 'visits' I was scheduled for an EGD with this doctor along with a 3 part stress test(breathing, legs and heart to check for clotting and exercise)...during the EGD I was also given a ultrasound of the gallbladder. This doctor was extremely thorough and was making sure that I was given every possible chance for the insurance to not deny me. When the package was submitted after all of the tests, I made sure to tell my insurance coordinator at the surgeons office additional things I wanted included such as my fitness gym contract, diseased gallbladder ultrasound, receipt from latest pcp appointment(that insurance company didn't show in their records)...I knew I had a better chance at approval if BCBS saw that not only was I being compliant but that I needed a cholesctomy(gallbladder removal) and that I would pursue the 2nd surgery until it was granted. With the cost of treating my comorbities, I'm sure the insurance saw that it was less expensive to grant the surgery than it was to treat the ailments that existed bc of my weight. By the amazing powers that God put in place, I was granted the second opportunity to change my life. My surgery took place December 14, 2017. Prior to surgery my co-morbidities were high cholesterol, hypertension, diabetes(with injections daily), edema in lower extremities. Please don't give up!!! My apologies for the long reply but I hope it helps someone that needs the strength to keep fighting. God Bless!

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[Shelbel 7]

Loved your reply. A lot of my problem is my father and most of his siblings (he had 12) suffer from insulin dependent diabetes. I don’t want to end up like them. I am considered pre-diabetic, so I included that in my letter to the insurance company. I used a large list of comorbidities, explaining some were mine but some were family history. I’ve still got my fingers crossed, and am glad I don’t have a deductible to meet. Thank you all for your positive poats. I’ll keep you updated.

[AceBlaque 17]

Thanks, you're in my prayers, it was my prayer when I submitted to my insurance that God placed the needed people in place that would be reviewing my case. I thought i had gotten denied bc my Drs office nor myself had heard anything from my bcbs in over two weeks, so I called to followup. The precertification dept told me that my case had been dismissed for lack of receiving my clinicals. I had to give them the date that tge clinicals were sent in and had been confirmed by bcbs. The pre-cert dept then said I was correct and that they didn't know why It had veen dismissed and that tgey would re-enter my information and submit it for review. It so happened that the original reviewer had the day off and my case was sent to another nurse that approved it the same day that I called. Make sure to ask your doctor if he/she will do a peer-to-peer conversation if you are denied. Please note that being affected mentally by weight complications is a reason for the surgery to be "medically necessary" (as long as the patient is psychologically cleared for the procedure) and some insurance companies will take that into account. Please keep me posted! Excited for you already!

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[Shelbel 7]

We have resubmitted to my insurance. Spoke with bcbs today. It’s still under review.

[Shelbel 7]

Just heard that I have been approved for surgery. I’m very excited. My surgery date has been scheduled for March 29.

[AceBlaque 17]

Omg!!! I feel like I just got approved all over again by what you getting yours!! I'm super proud and excited that you didn't give up!! March is right around the corner, yayyyy!!!!

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[kakatlady612 1,053]

I am so so happy for you. My fathers family, 10 siblings, all but 1 we're diabetic. I should be a surgery month twin so I'll be watching for updates as our month draws closer.



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