Florida Blue (BCBS of Florida) Medical Necessity

[UncleBeezy 7]

My Florida Blue (BCBS of Florida) policy excludes bariatric surgery; however, I am eligible for coverage with an approved application for “medical necessity”. Florida Blue defines medical necessity as:

Adults
Severely obese with a BMI ≥ 40 kg/m2, OR
Severely obese with a BMI ≥ 35 kg/m2, with at least one comorbidity refractory to medical management (e.g., type 2 diabetes, hypertension, coronary artery disease, obstructive sleep apnea, GERD, osteoarthritis, pseudotumor cerebri), AND
Does not have a medically treatable cause for obesity (e.g., thyroid or other endocrine disorder), AND Has made multiple attempts at non-surgical weight loss (e.g., diet, exercise, medications), AND
Has received psychological or psychiatric evaluation with counseling as needed, prior to surgical intervention.

I have a BMI of 49 and a diagnosis of obstructive sleep apnea for which I utilize a CPAP every night. I also meet all the other requirements listed above, AND my Primary Care Physician is writing a letter recommending bariatric surgery as a medical necessity.

Regardless, I am still nervous that my insurance will deny me. Has anyone else gone through the application/appeal process for bariatric surgery under a medical necessity?

Any advice on navigating that process would be much appreciated. Thanks!

[Walter Lindstrom 42]

First off, congrats on taking this giant step toward improving your health! I wish you the best in your journey. This is a fabulous and supportive community who will help you. Hopefully I can give you some important guidance.

Your statement about bariatric surgery being excluded on the one hand, but you having the chance to establish "medical necessity" on the other hand really are somewhat contradictory so be very, very sure you have the coverage you think you have. It's awful when folks go through the full process only to find out at the end they did not have coverage in the first place. Have you actually obtained a copy of your Florida Blue coverage certificate (Sometimes called a Summary Plan Description)? Remember you need to look at the full booklet, not just the Summary of Benefits and Coverage that's usually only a few pages long. If the exclusion includes words like "unless medically necessary" or similar, you should be OK. But you REALLY NEED to confirm coverage for your surgery exists - don't take the word of the "customer service" morons who answer their phones at Florida Blue. They aren't interested in customers, nor do they provide much service. I've attached their Medical Policy which was just revised in July. I'm also attaching their Medical Necessity checklist. Hope they help. Last quick thought: don't rely on your PCP writing a letter by itself. Be sure to have medical records which establish your OSA diagnosis and start gathering your proof of non-surgical weight loss efforts because no doubt you'll need those sooner rather than later. Good luck!

Bariatric Surgery CMN.doc

mcg.pdf