The first part of it is the right document. It seems to have very little in the way of information about the bariatric surgery requirements - can you find the bariatric policy?
Regarding appeals:
7.04 Disputed Claim.
To ensure that payment of claims is in accordance with plan provisions and that payment reduction is not the result of errors in claim processing, miscommunication or misinterpretation of policies, the following should be followed when a covered person disagrees with a denial or reduction of benefits.
The health care provider, covered person (or representative), or the committee’s representative should contact the claims administrator to determine why a claim(s) has been reduced or denied. If not a processing error, the claims administrator will explain why the claim reduction or denial occurred. If the claim(s) was incurred with a contracted provider, the claims administrator will explain the “hold harmless” provision of the contract and advise the caller of the patient’s liability for the claim. If the claim(s) was with a non-contracted provider, or if there were both contracted and non-contracted claims, the caller will be advised to write the claims administrator and request a review of the claim(s). The claims administrator will review the written request and respond in writing within 60 calendar days of receipt of the request. After review, if claims are still reduced or denied, a detailed written explanation will be given to the covered person of the reasons for the reduction or denial. At this time, the covered person will be advised of any additional levels of review available to them.
If the dispute regarding the claims cannot be resolved at the claims administrator level, the covered person can initiate an appeal. Such appeal is to be made in accordance with both the policies and the rules and regulations of the committee. The committee is authorized to promulgate such rules and regulations necessary to process appeals.
Ask for the policies and rules and regulations. They may include referring to an outside medical review organization (I’ve had this happen with a self-funded plan) for external medical review, even though the committee makes the ultimate decision.
I asked the question you suggested and received a reply stating that the Information in the BCBS policies are the bariatric surgery requirements. I pulled some info. from BCBS Medical Policy Manual and listed it below. I was also informed that the appeals information in the Plan Document is not specific to bariatric surgery but applies to any adverse determination. I also listed a insert of that Appeals Provision below.
I also called my surgeons office today to see where we stand on getting the test approved to measure my stomach. They stated that they had to submit clinicals and are waiting for a response back.
I can't express enough gratitude for your guidance. Thank you.
MEDICAL APPROPRIATENESS
Bariatric surgery is considered medically appropriate if ANY ONE of the following criteria are met:
An initial bariatric surgical procedure requested and ALL of the following:
Individual is 18 years of age or older
The Bariatric Surgery Precertification Request Form completed and submitted with the request for authorization
Diagnosis of morbid obesity classified as ANY ONE of the following:
Class 3 obesity with a BMI greater than or equal to 40 kg/m2
Class 2 obesity with a BMI 35 to 39.9 kg/m2 with ANY ONE of the following obesity related comorbidities:
Coronary artery disease
Type 2 diabetes mellitus
Obstructive sleep apnea
Hypertension (BP greater than 140 mmHg systolic and/or 90 mmHg diastolic)
Absence of ALL of the following excessive risk co-morbidities:
Contraindications to general anesthesia
Uncorrectable coagulopathy
Irreversible cardiopulmonary disorders (e.g. right heart failure, severe pulmonary arterial hypertension, advanced cardiomyopathy)
End-organ failure (e.g. end stage renal disease, candidate for transplant)
Metastatic or inoperable malignancy
Attending physician is someone other than the operating surgeon and his/her associates
Attending physician documents individual is able and willing to be compliant with the necessary post - procedural dietary restrictions
Attending physician documents attempts at a non-surgical weight loss program (e.g. dietary management, behavior modification, and/or exercise) with ALL of the following:
Most recent attempt was within 2 years of request for surgery
Weight has either remained stable or decreased
Non-surgical programs have not achieved desired weight loss
Comprehensive psychosocial - behavioral evaluation with ALL of the following:
Submitted by a clinician whose license authorizes them to conduct psychological evaluations, perform psychotherapy or counseling and administer and interpret psychological tests*
Clinical interview completed no more than one (1) year prior to request for initial surgery
At least one psychological test and/or assessment tool administered and evaluated (Possible choices: Minnesota Multiphasic Personality Inventory®-2, MMPI®-2-Restructured Form, or Millon®
Behavioral Medicine Diagnostic with bariatric norms)
Conclusion that individual is able and willing to comply with requisite dietary and behavioral modifications following surgery
(*NOTE: Currently only Licensed Senior Psychological Examiners (LPSE), Psychologists and Psychiatrists are contracted by BCBST for psychological testing.)
A subsequent bariatric procedure that is a correction (revision), or reversal of the previous bariatric procedure with ALL of the following:
The revision or correction is not an investigational procedure
Physician documented complication related to the original surgery (e.g., fistula, obstruction, erosion, disruption/leakage of a suture/staple line, band herniation, or pouch enlargement not due to
overeating)
A subsequent bariatric procedure that is a conversion of a previous bariatric procedure to a different type of bariatric surgery with ALL of the following:
The requested procedure is not an investigational procedure
Individual meets all of the criteria for an initial bariatric procedure (Note: documentation submitted for the initial bariatric surgery does not count toward meeting the criteria for the conversion procedure,
all documentation must be resubmitted)
Request is two (2) years or more since the initial surgery
Weight loss is less than 50% of initial procedure pre-operative excess body weight
Weight remains at least 30% over ideal body weight (using standard tables for adult weight ranges from the National Heart Lung and Blood Institute:
Classification of Overweight and Obesity by BMI, Waist Circumference, and Associated Disease Risks
www.nhlbi.nih.gov
6.05 Appeals Provision.
A covered person may request an appeal of a decision made by the claims administrator relative to the disposition of a claim, the utilization review guidelines, or as determined by Benefits Administration, administrative decisions made on behalf of the plan. The covered person must first exhaust any and all levels of the internal complaint or grievance process available through the claims administrator before initiating an external level of appeal. The covered person should first call the claims administrator at the telephone number listed on his/her insurance card. If the covered person has received correspondence pertaining to an inquiry, the covered person should ask for the correspondent by name to discuss the issue. If the covered person’s complaint cannot be resolved on an informal basis, they may submit a formal complaint in a manner designated by the claims administrator. The claims administrator may require the covered person to complete and file a “member grievance form” or other designated form. Such forms may be obtained by calling the claims administrator at the telephone number listed on the covered person’s insurance card. The complaint or grievance should be filed with the claims administrator within the specified timeframe and will be reviewed by a committee as designated by the claims administrator. Within 60 calendar days of receipt of the written complaint, the claims administrator will issue a written decision to all of the parties involved and will advise them of any further appeal options, including external appeal through an Independent Review Organization (IRO).
