Taking advice and seeing if anyone has any experience with BC/BS Federal 2012 restrictions:
      Running into some problems with BC/BS Federal definition of 'medical necessity'. I meet the criteria in the benefit book but according to new info I might not qualify . Something about 2 or more treated and uncontrolled comorbidities - is this the standard now?

I don't think anyone can advise you with what you have provided thus far - the "new info" is too vague. My guess is that the info in an up to date benefit book is the right answer, but I really don't know.

Larra

http://www.fepblue.org/benefitplans/2012-sbp/bcbs-2012-RI71- 005.pdf
pages 53-54
link is above for their policy

i am looking at FEP BCBS 2012 as i type this and it looks like nothing has changed since 2011. they have the same requirements. if you meet all their listed requirements and have a doctor write you a letter that this is a 'medicaly necessity' then the surgery should be a breeze to cover.

FEP BCBS approved my surgery in dec 2011 and i was a light weight with no comobidites. i just followed their guidelines and got my doctors to do the rest. its a long long process but just stay organized and get your duckies in a row and it should be easy:) good luck

 

Thanks Danni - you are right - that's exactly what I read thinking I would meet the criteria. The 'uncontrolled' came over the phone from Travis in Dr. Stewarts Dallas office. I haven't had an appointment yet, and have only discussed over the phone. But this doesn't sound right, think I'll try to schedule an appointment to see if I can get approved - at least try to get the process started. Thanks for the encouragement!

I have FEP BCBS and my comorbities are mostly controlled, but so far they have approved and paid for all of my pre-op testing, EGD etc. for the DS. Sure hope I don't have any surprises!

BCBS Fed follows the BCBS state you are in. Check those guidelines. They will be what you have to adhere to.

What if the state affilliate BC/BS has a total exclusion on all WLS, and does not even let employers have a choice to cover wls, as is the case with BC/BS of Kansas?  That would exclude the federal employee or dependant from what is normally covered under Federal BC/BS?

Little late responding, but it was my understanding that BCBS Fed follows the guideline of whatever state you are going to have surgery in. For example, if I was in AZ, and wanted to have surgery in CA, and had BCBS fed, I would have to follow BCBS guidelines in AZ. I have no personal experience, but had a friend that got hung up on the state guidelines, even though she had fed which said it would cover pretty much everything.

from what i have found the guidelines do not apply to state guidelines. fepbcbs has their own set of guidelines, requirements, coverages, ect.

when applying for approval they did try to follow the guidelines of utah state which is regence bcbs. i contacted them and told them to stop appliing me to the state insurance and only to federal. this solved my issues when they got confussed.

i did not meet the requirements to have surgery in utah (regence bcbs) but since i federal these did not apply to me, hence i was covered under a different set of requirements (which i met all the requirements)

I hae BCBS Federal Employees Plan. The benefits are not established at the state level, but rather are the same for all federal employees regardless of where they live.

I just received my approval from BCBS, after several appeals. However, mine is a revision, from VSG to DS. BCBS has really tightened up on their requirements for revisions. But not so much for their initial procedures.

I wouldn't read too much into the "uncontrolled" comorbidities. Your surgeon's office will know what documentation is required for BCBS. Good luck!

Donna

Donna we are almost on the same time line - I had VSG July 6, 2010 and now want to get the DS. Beating myself in the head for not doing DS complete the first time. Who is your surgeon? Travis in Dr. Stewarts office is one who passed on the 'uncontrolled' bad news - but hoping that is not correct and you give me hope!

Thanks to everyone *****plied - you've got me started researching again - and I've also read my BC/BS 2012 benefits - there are more hoops to jump through since it's a VSG wanting a DS. But I'm gonna keep trying to get more information from the doctor's office. It's difficult since Travis in Dr. Stewart's Dallas office is the one giving me the news about uncontrolled comorbids and this is over the phone only - I can't seem to get anyone from Dr. Stewarts office to correspond with me, even by email - open to suggestions. I'm going to pull all my records from VSG here and my PCP will try to figure out for myself if I meet requirements. But you guys have really given me hope.

Danni by lightweight do you mean under 40 BMI?

Donna - you are also DS from VSG and had to appeal - how many times? Are you 40 BMI or 35+? Did you have to document failed VSG while following all guidelines post VSG? I've followed but still did not help me lose a lot. Also saw where you are in Texas, any chance you used Dr. Stewart?

So glad I found this forum ... you guys are the BEST!! 

I would have to say that FEPBlue does not follow state guidelines. I am stationed abroad and from N. VA. I do not have to meet VA BCBS requirements; however, I do have to meet the FEPBLUE requirements. The only difference is since we live abroad I do not have to have prior approval; however, I am submitting for it anyway. My situation is slightly different and I will submit all the paperwork through BCBS directly.

For those who had surgery this year, what was your turn around time for the approval process?

I lived in one state and had my surgery in another and BCBS (state I lived in) was the one who handled it all.