BCBS and BCBS Federal

08-21-2004, 04:10 PM

I understand that BCBS recently accepted the Lap Band procedure. Is this for both BCBS and BCBS Federal? We have BCBS Federal & we just received our denial letter today saying he could have the gastric bypass surgery or gastric stapling procedures but not Lap Band or similar procedures. We're in TX & have been waiting patiently for the ins. to reply. Since they denied the Lap Band, can we appeal?

New Hope · 08-21-2004, 04:24 PM

Boy, I don't know about B/C. Just wanted to give you my support. Go for the appeal! You may be pleasantly surprised. Look up Alex's sample appeal letter where she fought her ins. about the band vs. bypass and WON! (in old posts)

Why is it they always send those type of letter so you get them on a Frid. p.m. or Sat.? I think it's planned so you can't contact someone until the following week. Grrrrrr.

08-21-2004, 04:47 PM

Thanks, we'll be asking alot of questions and probably alot of dumb questions but I'm not about to let that stop me from letting him get this surgery done. He has too many medical conditions already and no self-control so when the doctors found out that he wanted to do this they were tickled pink.

**Alexandra** · 08-21-2004, 06:46 PM

Quote:

Originally posted by richardlisa
I understand that BCBS recently accepted the Lap Band procedure. Is this for both BCBS and BCBS Federal? We have BCBS Federal & we just received our denial letter today saying he could have the gastric bypass surgery or gastric stapling procedures but not Lap Band or similar procedures. We're in TX & have been waiting patiently for the ins. to reply. Since they denied the Lap Band, can we appeal?

Hi there,

BCBS is not one company, it's 52 separate entities and the plan that applies to Federal employees is something else. What one does has no bearing on what any others do, although they often mirror one another's policies.

But the answer to your second question is OF COURSE you can appeal!! The specific steps you will take depend on your carrier, employer, state, and so on, but you absolutely can appeal any decision.

The letter you received should give you some information as to an appeal procedure. If not, your employee benefits handbook or insurace contract (certificate of benefits) should have it. From what you say it sounds like the denial was not based on medical reasons, which to me says you have a better chance than might otherwise be the case.

Good luck!!

Maurice · 08-22-2004, 04:10 PM

I have BLBS in MN as a secondary insurance, and after eight months, they have granted coverage. I'm not sure if it was in response to appeal, but I suspect they followed Medicare and now cover banding.

Goldie · 05-22-2007, 04:50 PM

I have Blue Cross Blue Shield Federal for the Washingotn, DC area. It started covering Lap Band in January, if you are more than 100 pounds over your ideal weight. They covered the surgery I had in February. If you are planning to file an appeal, you need to folow the procedures set out on the health care booklet put out by OPM. For my insurance, the first appeal is with the insurance cimpany, the second is with OPM.

dotofoz · 05-23-2007, 06:06 AM

Quote:

Originally Posted by Goldie

I have Blue Cross Blue Shield Federal for the Washingotn, DC area. It started covering Lap Band in January, if you are more than 100 pounds over your ideal weight. They covered the surgery I had in February. If you are planning to file an appeal, you need to folow the procedures set out on the health care booklet put out by OPM. For my insurance, the first appeal is with the insurance cimpany, the second is with OPM.

Yes I agree w/Goldie. I have BCBS HMO OHIO (FEP). I had NO problem getting approved for my surgery I had 2/24/07. I'd also check the plan brochure, but appeal thru OPM and beware of the cut off dates for appeal. Alexandra had posted an EXCELLENT appeal letter sample some time ago on this site, you might want to check that out too. Good Luck, and I'm sending you good vibes!!!! Keep us posted!