Question:
Does anyone know what specific criteria BC/BS Federal uses to determine medical
necessity? I called my customer service number and was told they could not provide this information. Since they will no longer make a pre-determination, this seems unfair to me. — Lynn T. (posted on October 25, 2000)
October 25, 2000
Lynn, I have Federal BC/BS and was approved the day I met my surgeon. His
patient consultant called BC/BS and they approved my hospital admission. I
had done all my homework though. When I went in I had typed out an
extensive history of dates of all diets I've tried, what the results were,
and if I was supervised by a doctor. I probably had 10-12 weight loss
attempts ont his list. I also had chart typed up listing all medications I
take and for what condition and date diagnosed. My co-morbs were HPB,
arthritis, asthma, depression, and borderline diabetic. I hope this helps
you, good luck.
— Beth W.
October 25, 2000
Donna, actually I'm still pre-op (surgery date Oct. 31) and I am aware of
the change with no longer pre-certifying. What they told me is they still
have to approve hospital admission as with any hospitalization and even
though they aren't guaranteeing payment, if they approve the
hospitalization with the diagnoses given, that there isn't any reason they
shouldn't pay. It is stated in their brochure as a covered expenses if it
is considered a medical necessity. What they approved in the surgeon's
office was my hospital admissions. Hope this makes sense.
— Beth W.
October 25, 2000
Donna, actually I'm still pre-op (surgery date Oct. 31) and I am aware of
the change with no longer pre-certifying. What they told me is they still
have to approve hospital admission as with any hospitalization and even
though they aren't guaranteeing payment, if they approve the
hospitalization with the diagnoses given, that there isn't any reason they
shouldn't pay. It is stated in their brochure as a covered expenses if it
is considered a medical necessity. What they approved in the surgeon's
office was my hospital admissions. Hope this makes sense.
— Beth W.
October 25, 2000
I have BC/BS Federal -- They would not "precertify" my surgery
either
but they did precertify my admission ... my doc had them fax him a copy of
their criteria for WLS (which is 100 lbs over your ideal body weight and
a BMI of 40 or greater) to determine if I qualified ... they pretty much
told him that if I met the criteria there shouldn't be any reason why
they wouldn't pay. AND if they precertify the admission for the surgery
why would they cover the surgery. If you meet the criteria I don't think
you will have a problem. Good Luck and God Bless!!
— Donna H.
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