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DENIED - Federal BCBS

vhowley

By vhowley, in Insurance & Financing

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vhowley    7

vhowley
Posted

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

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Sharon1964    2,530

Sharon1964
Posted

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)."

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vhowley    7

vhowley
Posted

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.

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Read2016    658

Read2016
Posted

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.

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Sharon1964    2,530

Sharon1964
Posted

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.

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vhowley    7

vhowley
Posted

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

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Christinamo7    4,041

Christinamo7
Posted

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.

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Sharon1964    2,530

Sharon1964
Posted

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

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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"...

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vhowley    7

vhowley
Posted

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.

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KristenLe    5,979

KristenLe
Posted

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.

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Acceber12    5

Acceber12
Posted

@@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.

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KristenLe    5,979

KristenLe
Posted

@@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.

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