Hi from Texas!

[Purple Frog]

Thank you, @Larra !
I plan on calling first thing in the morning. I anticipate it will be some work to get.

 

[southernlady]

Thank you, @Larra !
I plan on calling first thing in the morning. I anticipate it will be some work to get.

Actually you have the right to it so it should not take much. IF it's thru your employer, your HR person will have a copy and has to provide you with one.

 

[Purple Frog]

Actually you have the right to it so it should not take much. IF it's thru your employer, your HR person will have a copy and has to provide you with one.

Oh no. This is painful. They actually have NO idea what an Evidence of Coverage is.
Neither does her Team Lead. I've been on the phone for awhile now.

Since I'm federal, my "HR" doesn't handle insurance. Maybe OPM. But this is where the fun part starts. Trying to figure out who to call and then being told "I don't know what that is".

 

[Purple Frog]

Ok, now they said (BCBS), the federal employees don't have one.
Says the guy that's been there 17 years....

 

[DianaCox]

It is the CONTRACT between BCBS and the gummint - it is particular to the plan YOU chose, so you need to know the details for YOUR plan. It should be around 100 pages long.

 

[Purple Frog]

Hi Diana,

Thanks for taking time from your vacation (hope you're having fun!)
Is it the Service Benefit Plan Brochure or something different? That doc is 160 pages and talks about requirements for WLS, says I need comorbidities, but doesn't go into detail on what those are.

I can't figure out how to attach a pdf to a conversation.

 

[DianaCox]

Yes, that sounds like the right document - as usual, the gummint makes it nearly twice as long as other plan descriptions. You can upload by using the upload button next to the Post Reply button, as far as I know. It probably needs to be saved as a separate document on your computer - I don't think you can attach directly from an email.

 

[Purple Frog]

Page 62-63
I'll probably delete after you look at this.

**deleted doc**

 

[DianaCox]

OK, so the requirements are pretty straightforward and I don't see ANY requirement for comorbidities unless your BMI is less than 40:

• Benefits for the surgical treatment of morbid obesity, performed on an inpatient or outpatient basis, are subject to the pre-surgical requirements listed below. The member must meet all requirements.
  
  • − Diagnosis of morbid obesity (as defined on page 62) for a period of 2 years prior to surgery
    
    
  • − Participation in a medically supervised weight loss program, including nutritional counseling, for at least 3 months prior to the date of surgery. (Note: Benefits are not available for commercial weight loss programs; see page 40 for our coverage of nutritional counseling services.)
    
    
  • − Pre-operative nutritional assessment and nutritional counseling about pre- and post-operative nutrition, eating, and exercise
    
    
  • − Evidence that attempts at weight loss in the 1 year period prior to surgery have been ineffective
    
    
  • − Psychological clearance of the member’s ability to understand and adhere to the pre- and post-operative program, based on a psychological assessment performed by a licensed professional mental health practitioner (see page 97 for our payment levels for mental health services)
    
    
  • − Member has not smoked in the 6 months prior to surgery
    
    
  • − Member has not been treated for substance abuse for 1 year prior to surgery and there is no evidence of substance abuse during the 1-year period prior to surgery
    
• Claims for the surgical treatment of morbid obesity must include documentation from the member’s provider(s) that all pre-surgical requirements have been met.
• [from page 62] Gastric restrictive procedures, gastric malabsorptive procedures, and combination restrictive and malabsorptive procedures to treat morbid obesity – a condition in which an individual has a Body Mass Index (BMI) of 40 or more, or an individual with a BMI of 35 or more with one or more co- morbidities; eligible members must be age 18 or over

 

[Purple Frog]

Yup, that's what I thought when I read it which is why I was surprised when Ayoola's office said BCBS wouldn't cover the DS with my BMI (41) without comorbidities. But, maybe she didn't know what she was talking about. Because she also mentioned that I hadn't met my deductible and I don't have one.

So, this is the right doc? I can't stop insisting to BCBS that they are full of shit?? lol

 

[DianaCox]

Yup, this is what you needed to review. And let Ayoola's office know they suck at doing insurance pre-qualifications.

 

[Purple Frog]

Will do! Thank you, Diana!

 

[robs477]

Now that's some good stuff! Thank you Diana for helping her, especially when on vac, that was so cool of you! She really needed some of you guys expertise and Larra too and everyone else also, there is so much talent on here. In my "Lay" opinion, the only thing left to figure out is establishing a relationship with a PCP, or somehow posthumously putting together the history part. Even if it takes 6 months, It will be worth it, Hell I've waited 3 months, have 2-3 more to go and already had a history with 4 co-morbs...So, you should be able to make it all work it sounds like

 

[robs477]

Oh...you're one of those "go buy some rolls of quarters on your way to weigh in" people? I knew I kinda liked you!

OMG...I wasn't going to tell anyone this, but...since you brought it up! From all the Pseudo VAST morsel of knowledge I've obtained from you "Experts", I KNEW they were going to have a pre-condition for me to lose X amount of lbs as a "Pre-condition" for my Surgery, you know, the ole fatty liver thing.....So, I wore my Steel toed boots, my thickest jeans and a jacket. Sure enough...Dr. said, I need to lose 14 lbs as my "pre-condition" thingy, which really means about 8 lbs because on weigh in day, I will wear my lightest shorts, thinnest T-shirt and flip-flops, 6 lbs lighter...done deal!! I AM going to try to lose the weight, I know it cant hurt.....But WTF...If I could lose weight, why would I be having surgery????

 

[DianaCox]

"In my "Lay" opinion, the only thing left to figure out is establishing a relationship with a PCP, or somehow posthumously putting together the history part."

Posthumously is a little too late.