Question:
Has anyone had problems with getting approval with BC/BS PPO Fed?.
I'm getting nerveous that my surgery won't be approved because of all the comments about BC. The gal I talked to from BC told me the surgery has to be medically nesesary, but won't say what the criteria is. I have a BMI of 47 and have 3 comorbidities, if arthritis in knees counts. Any information will be appreciated. — Jean B. (posted on April 4, 2002)
April 4, 2002
It all depends upon which BC/BS and what is in your policy. Some BC/BS are
a breeze to get approval. My wife has BC/BS of Michigan traditional with
few comorbidities, a bmi of 42 and was approved in 2 days no questions
asked. I have Anthem BC/BS of Ohio/Indiana. I had 6 of the 7 comorbidities
that the NIH says make WLS medically necessary, and a bmi of 62 and they
denied me saying it wasn't considered as medically necessary. I faught them
for 4 months and ended up hiring a lawyer (obesitylaw.com).
Good luck and if you do have problems, keep at it and I highly recommend
the folks at obesitylaw.com if you are having problems getting approved.
— Dell H.
April 4, 2002
Hello! My husband and I have the Fed policy (standard option) that you
do... The criteria is you need to be at least 100lbs or 100% over your
ideal weight according to the MET life chart. We just had the surgery 3
weeks ago so insurance hasn't paid everything yet but they have started
too..Remember you have a 100 copay for the hospital (in-network) no matter
how long you are there or what the bill is..they also have rules about how
much you have to pay the surgeon.. ours in 10% of the allowable charge..
and the MOST you would HAVE pay is 4000 (castrophic clause)..... according
to our benefit people at work. Make sure you use in-network providers..
including the hospital..etc..and make sure you pre-certify.. there's a
phone # on the back of your insurance card.. so far they have paid the
anesthesia (sp?) bill and some other little ones....HANG IN THERE AND GOOD
LUCK!!!!
— Allie A.
April 4, 2002
allie is absolutely right about bc/bs fed. bc/bs fed is ENTIRELY DIFFERENT
than any other bc/bs policy in that the same benefits apply nationwide not
state to state. the catch is that the state u r having the surgery done in
is the 'administrative office.' but, again, we all have the same benefits
nationwide. dont expect to get an approval letter because they dont send
one to u. they will send a pre-certification letter & confirmation
number to ur surgeon. if u ask them, they will tell u that they dont
pre-approve wls, that they wait for the bills to be submitted to decide if
they will pay, but, they ALWAYS pay, so dont worry about it. ALL my bills
were paid in a very reasonable amount of time. i called & asked for the
confirmation number for my own peace of mind. i also called them to tell
them about the surgery because of that pre-cert condition on the back of
our id cards. it just made me feel better hearing them say...yes ur surgeon
notified us already. but, they do note ur records to reflect ur call so
that in the future they cant claim u didnt live up to ur responsibility. i
also asked them about my surgeons reputation with them & they were more
than pleased to tell me that he is one of their most popular surgeons with
a very low complication rate & that they issue a confirmation number as
soon as they see his name. so if u want to check out ur surgeon im sure
they will be just as helpful to u as they were to me. all in all, we r very
lucky to have the best bc/bs policy in the country, even tho it is very
expensive. good luck to u!
— sheryl titone
April 4, 2002
I have BC/BS FEP, and was approved last May, for my OpenVBG, over the phone
on the day of my very first consult with the surgeon. Two weeks later I had
the surgery and they paid it all but the $100. And, now - (130 lbs lost!),
they are paying for my Abdominoplasty coming up on May 16th.
— Cathy J.
April 6, 2002
I have the bc/bs fep standard option and was approved in a week. You do
have to meet the 100 pounds or 100% over the standard for your body weight.
They sent me a letter with the number and even called. I live in
virginia.
— Memory
August 19, 2002
HELLO, MY NAME IS CAMEO,
I HAD NO PROBLEM GETTING APPROVED BY B/C B/S PPO FEDERALS.
I HAD CRITERIA, FOR THIS SURGERY. I HAD 6 LETTERS FROM MY DRS, STATEING
WHY THIS WAS SO GOOD FOR ME TO HAVE THIS SURGERY. I HAD MY SURGERY JUNE 4TH
2002, AND HAVE LOST 53+ POUNDS IN THIS SHORT TIME. AND I WEIGHED 377.5 LBS
AT START NOW AS OF AUGUST 1RST WEIGH 325 LBS WOW I CAN;T BELIVE IT.
I HAVE HAD BOTH KNEES DONE, FOOT SURGERY, HIGH BLOOD PRESSURE, ARTHRU IN
BACK,KNEES ALL OVER ASTHMA.I TAKE TWO DIFFERENT B/P MEDCINES,I WROTE B/C
B/S. A LETTER WAS SENT IN BY MY SELF AND I SENT A PICTURE WITH THE LETTER
AND JUST SAID I NEED HELP I AM DYEING. IF YOU DON'T HELP ME GET APPROVED
YOU WILL TAKE CARE OF ME AFTER I HAVE A HEART ATTACK OR STROKE? SO IT IS UP
TO YOU I SAID EXACLTEY HOW I WOULD FEEL EACH AM. THAT I WASENT LIVEING JUST
EXICTING
SO FROM POINT A TILL SURGERY WAS 6 MONTHS, AND GOT ALL MY DUCKS IN A ROW,
FROM ALL OTHERS I HEARSD IT COULD OF TAKEN AS MUSH AS A YEAR OR SO. SO IWAS
LUCKY. I SAW THE DR ON MAY 13TH AND HE SAID IT MIGHT TAKE TWO-THREE MONTHS
FOR ARRROVAL
AND WITHIN 4 DAYS I GOT MY CALL OH APPROVAL SO DRS ASST SET UP SURGERY.
WOW. I COULDN;T BELIVE IT.MY BMI WAS 60 SO AND I HAD MEDICAL CRITERIA. SO
EVERDAY GETS A LITTLE BITT BETTER I HOPE ALL WENT WELL FOR YOU. PLEASE LET
ME KNOW HOW YOU ARE DOING AND WHATS HAPPENING OK, MY E-MAIL ADRESS IS
[email protected] OK GOD BLESS I HOPET I HELPED YOU WITH THIS
DON;T GIVE UP OK. YOU NEW SISTER CAMEO
— CAMEO B.
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