Need Advise Please

Hello, everyone! I am kinda new, I posted a few times months ago when I first begin my fight to get wls and have been a faithful lurker every since. I am in need of some advise. I posted on the insurance board as well, but am hoping someone local may have some info. This is going to be kind of long so please forgive me but I need to give a little background info.
I have BCBS of IL through my husbands employer, it is a self funded plan.  There is a written exclusion for gastric bypass which reads:

" Services and supplies rendered or provided for gastric bypass surgery." 

The surgeons office sent in a pre approval request specifically for RNY  and of course I got denied.  I hired an attorney and tried to get the decision overturned to no avail.   So, here is my question:  Do you think it would be worth it to try and get the Sleeve approved since the exclusion is written so specifically to bypass?  And if so how do I go about doing that with out getting the surgeon involved again?  My current surgeon does not do the sleeve and I live in Sapulpa so it is a bit of a drive  to weight wise , and they will not submit it until I drive up there and go through the seminar and have a consultation appointment. (which I have already done with my first surgeon at a price of $200)  I really don't want to drive up there 2 different times and spend the money for the consultation until I know if I can get approved.  Any info or suggestions will be greatly appreciated! Thanks!!!!

Which doctor did you use?  There is a bariatric surgeon in Bartlesville and there are now TWO at Bailey in Owasso.  Does your husband only have one plan choice at work or are there two or three different ones that could be chosen from?  There is a chance that nother plan may cover it, it's almost sign up time for 2010 (where did the time go?) and that may be an option you can use rather than paying out of pocket for the surgery.

I used Dr. Gorospe. I did not know there was one in Bartlesville, I will look them up. Also I did not know that there is another Dr. at Bailey, I will look into that as well.
There are different plans to chose from, however they all exclude. It is the company that has the exclusion, not the insurance. Thanks for the great info!

The other doctor at Bailey is pretty new.  I went in for my 6 month check up and saw that they had a sign up for him but it wasn't one of the professional signs.  Also Dr. Gorospe is doing the sleeve now so I don't believe that you would have to pay your 200.00 again if you wanted to check into that.

That is awesome, I did not know he was doing the sleeve. Thanks for letting me know. I will call them tomorrow.

I'm curious about the language on that exclusion, too. 

" Services and supplies rendered or provided for gastric bypass surgery." 

That indicates to me that only the RNY is not covered.  Banding and Sleeves are not technically a bypass operation.  My point is that you could argue with them on a sleeve or band and get it covered because their language does not specifically exclude them.  That might screw it up for others that follow but it might mean no money out of pocket for you since BCBS would likely change the language.

I would ask the lawyer or the docs by phone and see what they say.  Insurance companies are notoriously narrow-minded when it comes to WLS.  I love to see them get caught by their own language!

I would agree with this post.

I think you could argue and get them to cover a band or sleeve surgery, but I'm sure as soon as you won they would be changing the language to exclude ALL WLS so as to not having to foot the bill for other people.

Best of luck sweety! *BIG hugs*
Do keep us updated on your progress. You are in my prayers!!

Thank you every one for the great advise.  I contacted Bailey Med Center and they refused to even try and submit it to insurance. My case worker there said that there is absolutely no insurance anywhere that will pay for the VSG.
I also tried to call BCBSIL and find out and they told me to call my employer, so I did and they told me to have the DR. submit it to BCBSIL to get an answer. ARRRRRR so frustrated!!!!  I give up! I am just going to have to bite the bullet and self-pay.

Who is your case worker working for?  You or the insurance company?  Call that case worker back and demand that they try based on the flimsy language.  If the case worker won't help, move up to the supervisor.  Keep going up the chain of command until you get satisfaction.  If you don't get satisfaction, go to another hospital and a different program. 

Don't let them push you around!

Yeah. Don't let them get the best of you and tell you just what can and can't be done. Get someone in YOUR corner with YOUR best interest in mind, not the insurance company. I mean how much money have YOU put in THEIR pocket?? It's time they helped you when you are in need. If you have gone to a doctor and they said it is a needed surgery for your health, then I can't see that it could be denied.

Good luck sweety! Fight the good fight!
*SUPER BIG HUGS*