Jump to content
×
Are you looking for the BariatricPal Store? Go now!

DENIED - Federal BCBS



Recommended Posts

I have surgery scheduled for 17 May 16. BMI is 39 - have Moderate sleep Apnea. Did medically supervised diet from Dec 2014 - May 2015 and every possible diet known to man, multiple times.

Reason for denial is that the 3 month medically supervised diet was not within this last year. Nowhere in the 2016 FEP BCBS brochure does it say WHEN you had to participate in a 3 month program. I was also medically supervised from Apr 2006 - Dec 2006 when I represented Pennsylvania on Season 3 of the Biggest Loser.

Can anyone advise on how best to challenge this? I don't want to wait another 90 days to check a block. I've been battling and battling and battling for years....post-291665-14625071218676_thumb.jpg

Sent from my iPhone using the BariatricPal App

Share this post


Link to post
Share on other sites

Read the denial letter to determine how to start your appeal. Then, if it is write a letter, you will want the letter to be no more than one page. Quote the section of the benefit manual that specifies supervised diet, and quote the portion of the denial letter that applies.

Your kicker will be, "As you can clearly see from the quoted benefit, there is no requirement as is quoted in the denial letter. Please overturn the improper denial and issue an authorization for the (name of surgery), to be performed by (name of doctor) at (name of hospital)."

Share this post


Link to post
Share on other sites

Thank you! I haven't received the denial...only the surgeon's office has...so far. I logged into fepblue.org to see if I could find the denial, but it's not there yet.

Sent from my iPhone using the BariatricPal App

Share this post


Link to post
Share on other sites

I have not been denied as of yet... I'm preparing in the event that happens... If you read the online there is no medical research to support that a six month diet will have any impact on obesity... Obesity has been determined to be a disease by the AMA in April 2014... Diseases need treatment not waiting period... It's a bias policy that works to promote society's bias of obese people... It assumes obese people don't have the knowledge regarding health eating etc... It's disgraceful that obesity is the only disease where you have to fight to get treatment and prove your efforts... Skin cancer patients aren't ask to prove they used sunscreen... No other disease requires you to provide proof of your effort to manage the disease.

Sent from my iPhone using the BariatricPal App

Share this post


Link to post
Share on other sites

When you get the denial, let me know if you need help crafting the letter. I've done this (appealing denials for medical care, not necessarily bariatric surgery denials) from the physician's side for a long time, and my success rate is pretty good, but persistence is key.

Share this post


Link to post
Share on other sites

I received my denial letter and drafted an appeal...would appreciate any feedback/suggestions on how to improve it. My doctor is doing the peer-to-peer call this afternoon...hoping for a miracle approval so I won't need to appeal...

post-291665-14628195916563_thumb.jpg post-291665-1462819610569_thumb.jpg

Sent from my iPhone using the BariatricPal App

Share this post


Link to post
Share on other sites

you've already gotten such good counsel here - but I just wanted to add that I hope you can get this overturned and not have to do yet another 3 month supervised diet.

I have fed BCBS standard.

Share this post


Link to post
Share on other sites

I received my denial letter and drafted an appeal...would appreciate any feedback/suggestions on how to improve it. My doctor is doing the peer-to-peer call this afternoon...hoping for a miracle approval so I won't need to appeal...

attachicon.gifImageUploadedByBariatricPal1462819585.303868.jpgattachicon.gifImageUploadedByBariatricPal1462819602.936880.jpg

Sent from my iPhone using the BariatricPal App

You've done great. The only thing I would change is on page two, where you say that there is no requirement for recent participation...

Change it to: Not only is there no definition of "recent", there is in fact no requirement for "recent participation"...

Share this post


Link to post
Share on other sites

Thank you Sharon! Great suggestion! I'm dying to know how the peer-to-peer discussion went. Apparently, my doctor made the call in between surgeries, so I'll have to wait til tomorrow.

Sent from my iPhone using the BariatricPal App

Share this post


Link to post
Share on other sites

Great letter. Check the Obesity Action Coalition website for other tips on appealing. I'm having a difficult time getting my BCBS carrier to provide me with my requirements and it's frustrating not to know the details.

Share this post


Link to post
Share on other sites

@@KristenLe - is your health plan through work? If so, you can request the plan document from your HR person. The plan document should outline whether WLS is covered and any prerequisites for coverage.

Sent from my iPhone using the BariatricPal App

Share this post


Link to post
Share on other sites

@@Acceber12 Yes - and the plan coordinator has been unable to get the details too. I called BCBS again and they told me my surgeons office would need to find out what was required for a prior authorization. It's unbelievable that they won't give me the info - I'm the policy holder.

Share this post


Link to post
Share on other sites

Create an account or sign in to comment

You need to be a member in order to leave a comment

Create an account

Sign up for a new account in our community. It's easy!

Register a new account

Sign in

Already have an account? Sign in here.

Sign In Now

  • Trending Products

  • Trending Topics

  • Recent Status Updates

    • Doughgurl

      2 days until I fly out to San Diego to have my Bypass Surg. in Tiajuana Mexico. Not gonna lie, the nerves are starting to surface. I don't fear the surgery itself, or the fact that I'm traveling alone, but its the aftermath that I'm stressing about the most, after this 8 week wait. I'm excited to finally be here, but I am really dreading the post surgical chapter. I know its going to be tough, real tough and I think I'm just in my head to much now that the day i here. Wish me luck, Hopefully I'm one of the lucky ones, and everything goes smoothly. Cant wait to give an exciting update,. If there is anyone else have a June bypass or even a recent one, Id love to have someone to compare war stories with. Also, anyone near San Antonio Tx? See ya soon with the future me. 💜
      · 0 replies
      1. This update has no replies.
    • LeighaTR

      I am new here today... and only two weeks out from my sleeve surgery on the 23rd. I am amazed I have kept my calories down to 467 today so far... that leaves me almost 750 left for dinner and maybe a snack. This is going to be tough for two weeks... but I have to believe I can do it!
      · 0 replies
      1. This update has no replies.
    • Doughgurl

      Hey everyone. I'm new here so I thought I should introduce myself. I am 53y/o and am scheduled for Gastric Bypass on June 25th, 2025. I'm located in San Antonio, Texas. I will be having my surgery in Tiajuana Mexico. I've wanted this for years, but I always had insurance where bariatric procedures were excluded. Finally I am able to afford to pay out of pocket.  I can't wait to get started, and I hope I'm prepared for the initial period of "hell". I know what I have signed up for, but I'm sure the good to come will out way the temporary period of discomfort and feelings of regret. I'd love to find people to talk to who have been through the same procedure or experience before. So I look forward to meeting you all. Hope you have a great week!
      · 2 replies
      1. Selina333

        I'm so happy for you! You are about to change your life. I was so glad to get the sleeve done in Dec. I didn't have feelings of regret overall. And I'm down almost 60 lbs. I do feel a little sad at restaurants. I can barely eat half a kid's meal. I get adults meals often because kid ones don't have the same offerings at times. Then I feel obligated to eat on that until it's gone and that can be days. So the restaurant thing isn't great for me. All the rest is fine by me! I love feeling full with very little. I do wish I could drink when eating. And will sip at the end. Just a strong habit to stop. But I'm working on it! You will do fine! Just keep focused on your desire to be different. Not better or worse. But different. I am happy both ways but my low back doesn't like me that heavy. So I listened (also my feet!). LOL! Update us on your journey! I'm not far from you. I'm in Houston. Good luck and I hope it all goes smoothly! Would love to see pics of the town you go to for this. I've never been there. Neat you will be traveling for this! Enjoy the journey. Take it one day at a time. Sometimes a few hours at a time. Follow all recommendations as best you can. 💗

      2. Doughgurl

        Thank you so much for your well wishes. I am hoping that everything goes easy for me as well. We don't eat out much as it is, so it wont be too bad in that department. Thankfully. Also, I hear you regarding your back and feet!! I'd like to add knees to the list. Killing me as we speak! I'm only 5' so the weight has to go. Too short to carry all this weight. Menopause really did a doosey on me. (😶lol) My daughter also lives in Houston. with her Husband and my 5 grand-littles. I grew up in Beaumont, so I know Houston well, I will be sure to keep in touch and update you on my journey. I may need some advice in the future, or just motivation. Thank You so much for reaching out, I was hoping to connect with someone in the community. I really appreciate it. 💜

    • Alisa_S

      On day 4 of the 2 week liquid pre-op diet. Surgery scheduled for June 11th.
      Soooo I am coming to a realization
      of something and I'm not sure what to do about it. For years the only thing I've enjoyed is eating. We rarely do anything or go anywhere and if we do it always includes food. Family comes over? Big family dinner! Go camping? Food! Take a short ride or trip? Food! Holiday? Food! Go out of town for a Dr appointment? Food! When we go to a new town we don't look for any attractions, we look for restaurants we haven't been to. Heck, I look forward to getting off work because that means it's almost supper time. Now that I'm drinking these pre-op shakes for breakfast, lunch, and supper I have nothing to look forward to.  And once I have surgery on June 11th it'll be more of the same shakes. Even after pureed stage, soft food stage, and finally regular food stage, it's going to be a drastic change for the rest of my life. I'm giving up the one thing that really brings me joy. Eating. How do you cope with that? What do you do to fill that void? Wow. Now I'm sad.
      · 1 reply
      1. LeighaTR

        I hope your surgery on Wednesday goes well. You will be able to do all sorts of new things as you find your new normal after surgery. I don't know this from experience yet, but I am seeing a lot of positive things from people who have had it done. Best of luck!

    • Alisa_S

      On day 4 of the 2 week liquid pre-op diet. Surgery scheduled for June 11th.
      Soooo I am coming to a realization
      of something and I'm not sure what to do about it. For years the only thing I've enjoyed is eating. We rarely do anything or go anywhere and if we do it always includes food. Family comes over? Big family dinner! Go camping? Food! Take a short ride or trip? Food! Holiday? Food! Go out of town for a Dr appointment? Food! When we go to a new town we don't look for any attractions, we look for restaurants we haven't been to. Heck, I look forward to getting off work because that means it's almost supper time. Now that I'm drinking these pre-op shakes for breakfast, lunch, and supper I have nothing to look forward to.  And once I have surgery on June 11th it'll be more of the same shakes. Even after pureed stage, soft food stage, and finally regular food stage, it's going to be a drastic change for the rest of my life. I'm giving up the one thing that really brings me joy. Eating. How do you cope with that? What do you do to fill that void? Wow. Now I'm sad.
      · 1 reply
      1. summerseeker

        Life as a big person had limited my life to what I knew I could manage to do each day. That was eat. I hadn't anything else to look forward to. So my eating choices were the best I could dream up. I planned the cooking in managable lots in my head and filled my day with and around it.

        Now I have a whole new big, bigger, biggest, best days ever. I am out there with those skinny people doing stuff i could never have dreamt of. Food is now an after thought. It doesn't consume my day. I still enjoy the good home cooked food but I eat smaller portions. I leave food on my plate when I am full. I can no longer hear my mother's voice saying eat it all up, ther are starving children in Africa who would want that!

        I still cook for family feasts, I love cooking. I still do holidays but I have changed from the All inclusive drinking and eating everything everyday kind to Self catering accommodation. This gives me the choice of cooking or eating out as I choose. I rarely drink anymore as I usually travel alone now and I feel I need to keep aware of my surroundings.

        I don't know at what point my life expanded, was it when I lost 100 pounds? Was it when I left my walking stick at home ? Was it when I said yes to an outing instead of finding an excuse to stay home ? i look back at my last five years and wonder how loosing weight has made such a difference. Be ready to amaze yourself.

        BTW, the liquid diet sucks, one more day and you are over the worst. You can do it.

  • Recent Topics

  • Hot Products

  • Sign Up For
    Our Newsletter

    Follow us for the latest news
    and special product offers!
  • Together, we have lost...
      lbs

    PatchAid Vitamin Patches

    ×