Fed BCBS anyone? Approved/Denied?

[KimB7811 115]

Hey guys! I’m scheduled for sleeve surgery this Thursday, the 25th. However.....we are STILL waiting on my insurance approval!!! Nothing like cutting it close. Just wondering if anyone has Fed BCBS insurance and if you got denied, what was the reason? Or if you got approved, how long did it take? My insurance coordinator submitted everything last Monday but I have a bad feeling I’m going to be denied....

[ahillig 136]

Curious if you got approved before your surgery date! I have the same insurance and I have this sinking feeling that I'm going to get denied. I might just call them and ask for clarification as to what exactly they're looking for in regards to approving it.

[KimB7811 115]

Hi! Yes, I got the approval on the 23rd and they submitted everything on the 15th. They were off for Good Friday so it took 6 business days to get the approval. They did however, ask for more info on the 17th and my insurance coordinator faxed it over that same day. They seemed to be most picky about seeing my weights for the year. Here’s the requirements taken right out of my plan for the Bariatric surgery. I have the basic plan. Just make sure you get as many letters of medical necessity from all your drs. Especially your primary. That seems to help things. Good luck and keep me posted!!!

Procedures to treat morbid obesity – a condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with one or more co-morbidities; eligible members must be age 18 or over. Benefits are available only for the following procedures:

o Roux-en-Y

o Gastric bypass

o Laparoscopic adjustable gastric banding

o Sleeve gastrectomy

o Biliopancreatic bypass with duodenal switch

Note: Benefits for the surgical treatment of morbid obesity are subject to the requirements listed on pages 66-67.

Note: For certain surgical procedures, your out-of-pocket costs for facility services are reduced if you use a facility designated as a Blue Distinction Center. See page 91 for information.

Note: Prior approval is required for outpatient surgery for morbid obesity. For more information about prior approval, please refer to page 23.

• Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the pre-surgical requirements listed below. The member must meet all requirements.

o Diagnosis of morbid obesity (as defined above) for a period of 1 year prior to surgery

o Participation in a medically supervised weight loss program, including nutritional counseling, for at least 3 months prior to the date of surgery. (Note: Benefits are not available for commercial weight loss programs; see page 41 for our coverage of nutritional counseling services.)

o Pre-operative nutritional assessment and nutritional counseling about pre- and post-operative nutrition, eating, and exercise

o Evidence that attempts at weight loss in the 1-year period prior to surgery have been ineffective

o Psychological clearance of the member’s ability to understand and adhere to the pre- and post-operative program, based on a psychological assessment performed by a licensed professional mental health practitioner (see page 104 for our payment levels for mental health services)

o Member has not smoked in the 6 months prior to surgery

o Member has not been treated for substance use disorder for 1 year prior to surgery and there is no evidence of substance use disorder during the 1-year period prior to surgery

[ahillig 136]

So happy you had your surgery!!

That's what mine says as well. I had some gyne issues over the past year so my weight record is pretty rock solid there. My only questions are the nutrition assessment and the physician supervised diet. My PCP said that I'll go see her for 3 mos, get weighed and talk about what I've been eating and how to improve that then give those notes to my surgeon. My surgeons office has a dietician on staff and they require a meeting with her before surgery so I guess that'll count, at least that's what my surgeon said. My PCP said that most of her patients who have had WLS have been successful and she seemed supportive so I don't think I'll have any problems getting the medical necessity from her.

[tiger_mom2001 16]

I have Federal BCBS basic as well. I'm just trying to get an initial consult with a surgeon. I was told since my BMI was 38.9 on 12/31/18 I would need to have "comorbidities." I listed several such as family history of heart disease, diabetes, kidney failure and my health history of asthma, GERD, gallbladder disease, and osteoarthritis. The surgeon office called today and reported I wouldn't qualify. The office reported I needed to have sleep apnea, high blood pressure, high cholesterol or diabetes. Does this sound right? I was discouraged but there is another blue distinction center that I will look into.

Sent from my SM-G955U using BariatricPal mobile app

[tiger_mom2001 16]

Hey guys! I’m scheduled for sleeve surgery this Thursday, the 25th. However.....we are STILL waiting on my insurance approval!!! Nothing like cutting it close. Just wondering if anyone has Fed BCBS insurance and if you got denied, what was the reason? Or if you got approved, how long did it take? My insurance coordinator submitted everything last Monday but I have a bad feeling I’m going to be denied....

I have Federal BCBS basic as well. I'm just trying to get an initial consult with a surgeon. I was told since my BMI was 38.9 on 12/31/18 I would need to have "comorbidities." I listed several such as family history of heart disease, diabetes, kidney failure and my health history of asthma, GERD, gallbladder disease, and osteoarthritis. The surgeon office called today and reported I wouldn't qualify. The office reported I needed to have sleep apnea, high blood pressure, high cholesterol or diabetes. Does this sound right? I was discouraged but there is another blue distinction center that I will look into.

Sent from my SM-G955U using BariatricPal mobile app

BTW, my BMI is 42 now.

Sent from my SM-G955U using BariatricPal mobile app

[KimB7811 115]

2 hours ago, tiger_mom2001 said:

I have Federal BCBS basic as well. I'm just trying to get an initial consult with a surgeon. I was told since my BMI was 38.9 on 12/31/18 I would need to have "comorbidities." I listed several such as family history of heart disease, diabetes, kidney failure and my health history of asthma, GERD, gallbladder disease, and osteoarthritis. The surgeon office called today and reported I wouldn't qualify. The office reported I needed to have sleep apnea, high blood pressure, high cholesterol or diabetes. Does this sound right? I was discouraged but there is another blue distinction center that I will look into.

Sent from my SM-G955U using BariatricPal mobile app

I would definitely go see another Dr. my BMI at the start of this all was only 35.8 but I had comorbitities of high blood pressure, osteoarthritis and after having the endoscopy, found out I had GERD. My family history is very long of diabetes and heart disease too. It really helps to have letters of medical necessity from all the drs though. For instance, I need a complete knee replacement so I also had my orthopedic write a letter of necessity for this surgery.