Carefirst BCBS, don't even bother???

My mother was talking to one of the WLS surgeons in her area (near Salisbury, MD).  They told her to not even bother trying to get approved for the Lap Band through Carefirst. Why would they tell her that?? They said they have an exclusion policy. But this was coming from the surgeon's office, NOT my mom's employer, and NOT by BCBS.  I've seen plenty of Carefirst customers get approved for LapBand. They jump through the same hoops as just about everyone else (6mo. diet, co-morbidies, etc)  I told her to contact Carefirst directly.

Has anyone experienced this?  I could tell she was really disappointed.  I'm pissed off because I feel like they are conning my mother in some way.

she should talk to her HR people.  every BC/BS plan is different based on state and employer.

That's what I told her. I just don't understand why the surgeon's office would flat out tell her it won't be approved.  I would guess they have experience with all the different plans, but still. It's worth a try. All they can say is "denied".

Most of the exclusions I have heard about are set at the employer level for the plan that they offer to their employees. I did not have the band, but for me RNY was the better choice. I still had to meet a bunch of criteria for BCBS. My primary care MD also has BCBS and wanted the RNY, but they would only cover the band for her because her business fell into the small group category (under 50 employees).

I agree, if WLS surgery is the right option for you, then I would suggest pursuing it further. You could even call BCBS directly and ask them what their current criteria are for your plan. That way you will receive the info directly.

I have Carefirst Bluechoice, don't know if that's different from BCBS. Im awaiting approval now. The surgeons office did tell me though that they have revamped their whole system and they are one of the biggest pains right now.

Everyone is right about saying every plan is different based on the employer group. Tell your mom not to give up yet. She needs to talk to BCBS directly and have them look at HER specific plan (usually called "Evidence of Coverage" or "EOC") and also ask them if they have a written policy they can give her regarding approval for the procedure.

I work for an insurance company in the department that approves things like this and I must look at 100 different EOC's every day to determine what level of coverage each patient has.

Good luck!!
Erin

You've gotten good advice to give your Mom, Lisa.  I, too, would tell her to get her info straight from the horse's mouth - and to document with whom she spoke!!!  It's hard to keep track of all of the info during the process, and I found it really helpful to document EVERYTHING.

Good luck to her,
Tia

As others have suggested, have your mom call the Member Services telephone number on her member ID card.  The CSR she calls should be able to look up her plan and see what type of WLS's are covered by her plan.  Also does she have any sort of plan contract or EOC?  She might be able to find some info in there that further explains what is covered.

Good luck!

Hello Lisa,, I have BCBS federal I called them to ask what wls is covered and they told me they need procedure codes. What the heck do they mean? I asked cant they just tell She said no. Why cant they tell me what wls is covered ?

                                                                                                    Julie

Julie that's a crock. they told me exactly what was covered.  what did you ask them?