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!