Holiday Cheer if you're covered by the Federal Employee Plans!

MAJOR CHANGE coming in 2019 for Federal Employee Coverage

I discovered something very important while I working on a patient’s appeal to the Office of Personnel Management (OPM).  In that case we are seeking to overturn the plan’s denial of a second surgery after we successfully overturned the original denial that included removing a failed laparoscopic adjustable gastric band.  I wanted to share something I uncovered when I was reviewing the Federal plan coverage for 2019 because I noticed a pretty significant change that may help patients who are covered in 2019 under the Federal Employees Benefit Plan (FEP).  For many years their medical criteria for bariatric surgery used to require a TWO-YEAR history of morbid obesity.

Guess What?  That is changing to ONE YEAR starting January 1st:

“We now provide bariatric surgery benefits for members who have a diagnosis of morbid obesity for a period of 1 year prior to surgery. Previously, the requirement was a diagnosis of morbid obesity 2 years prior to surgery. (See page 69.)”  

This impacts all potential patients covered under the FEP program who cannot establish a 2-year history whether they are requesting an “original” procedure or a revision / conversion for reasons other than a “complication” related to their original surgery (which is needed under the FEP plan).  

Personally I think it is going to improve the odds of getting many FEP revision/conversion patients approved when there aren’t the obvious complications like leaks, slips, erosions, strictures, etc.  It is also likely to help those patients who are trying to get covered for their first bariatric procedure but their BMI is on the lower end of the scale.  For example, it improves the odds of someone getting access to care if they had a BMI ranging from 35-39 for the past year (with appropriate co-morbid conditions, of course) but wouldn’t be approved in the past because their BMI was under 35 the year before that.  In short, I am cautiously optimistic this change will help almost anyone covered by FEP to access bariatric surgery.  I hope it helps.

Here is the link to the entire coverage document 2019 FEP Service Benefit Plan.

 

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