Blue Cross Blue Shield --- Employee??

Hi. I'm new here. I just went to work for BCBS of TN. I work in the Bluecare Division. However, I don't know much about my own insurance policy yet. I haven't had time to read everything and all that good stuff. I was wondering if there is anyone else out there that works for BCBST somewhere in the state who knows about the policies. I went to a meeting tonight for weight loss surgery here at a local hospital. I had the please of meeting Dr. Jaime Ponce and Dr. Fromm. There was also a guy there that had the lap-band done a year ago and has lost 200 pounds. I spoke with him after the meeting and he works for BCBST in the computer department. He told me that the group we are in (44 i think he said) has a clause or whatever written in saying they won't pay for the lap-band. This was such a disappointment to hear. I hadn't approached the company yet about this surgery, but his words were disappointing. He said he had to pay out of pocket and the cost was $18,000 for the hospital and surgeon fees. That doesn't include the the facility charges when you go in to have your fills at a later date. I'm very depressed at the moment. That really dampens my spirits. But I guess I'm going to try to go ahead and get everything together and submit it to my insurance anyways and just see what they say. I guess I'll never know until I try and see something in writing. Self-pay is not an option for me. I could never come up with that kind of money, unless someone out there wants to pay for it Anyways, just wanted any words of advice that anyone can offer. Thanks, B

Brandy, Hey dont give up. One of the other things you could try is checking with someone in your benefits dept. They should be able to direct you to the correct exclusions or inclusions in your plan. I have BCBSMA, and although I know that each plan is different, don't give up. I was the first person in all of my facility to have weightloss surgery, and nobody else in my company even knew that our plan did cover the surgery. BTW my wife had the lap band at Memorial with Dr. Walter Rose. Dr.Ponce's group did not take our insurance. This could be the reason that your friend self payed if he chose Ponce's group. Hope that you are able to find out more info in the future from others. God Bless, Michael

Brandy H, I don't work for BCBS but they are my health insurance carrier. I have it through federal employee (I don't know if that makes a difference). They covered my Lap RNY in February and approved my husband for the same surgery; however, he was unable to have the surgery due to health issues. The doctor did say she would do lap-band on him but BCBS of Tn said they would not cover it. Go figure! Sorry for the delay in response..........I just saw your post.

Thank you for your replies. I'm not going to give up hope at all. I emailed the benefits department and told them that I want the policies in writing. I requested that they mail everything to me about lap-band surgery. Whether they cover it or not, and the reasons for or against! I want to have this surgery. I NEED to have this surgery, for many reason. And your words of encouragement help me. Thank you.

Hello Brandy, I have bcbs of tn ppo and it wasn't until 9-1-04 that they started covering the lap-band surgery so I'm sure that's why that man had to pay for it out of his pocket. I haven't been approved to have it yet but that is because I still have a seminar to attend. I've already had a sleep study and are working on the other testing to get them out of the way, but PLEASE BE AWARE that anything that is coded as obesity in preparation for this surgery WILL NOT be covered by our insurance. I have not been morbidly obese for 5 years so I have to have 6 month medically supervised diet (per my dr because he thinks it will get me approved quicker) and because it's obesity related none of the office visits are paid for, the dietary consult isn't paid for, and my dr wanted to do a 3 hour glucose to make sure that I didn't have diabetes and he coded it as obesity and they wouldn't pay for the blood test so he then added the code for diabetes and I'm still awaiting the results of that....as for the sleep study I just found out today that it's going to be paid for but I don't know about the psych eval because I have yet to schedule it. I hope that this helps you some and please keep me posted of any information that you run across...I'm going to a seminar on dec 21st!!! Good Luck, Jen

I have BC/BS also govt employees, don't know how that differs exactly but I have been told by the surgeon's office that my insurance will pay for this if I meet the critera. I am still in the pre-workup phase and hitting road blocks. As I have already posted here, no help from my pcp doctor. He is into mesotherepy. I have been seeing him for over 10 years and liked him fine for general care, but when I asked for a letter of necessity for this surgery he told me "what you need is surgery on your brain". He is against all this. so I am having to start over with a new doctor and can't get a new patient appt until in March! Oh well, what have I got to lose but time and weight!

OH, EXCUSE ME!!! I somehow got to Tennessee MB instead of Texas! Anyway your post was informative to me. good luck all!

Hi All -- Thank you so much for all of your words of encouragement. As I said earlier, I sent an email about the lap-band surgery to someone in the Benefits Department, or where ever it went. The letter states: "This letter is in reponse to your recen tinquiry concerning the eligibility of Lap-Band Surgery for the above member. This information provided today is based on curren eligibility and contract limitations. Final determination will be made upon the completion of the processing of your claim. Under the terms of your policy, benefits would not be eligible for the servieces described. Services or supplies related to Obesity, including surgical treatment for morbid obesity is excluded on this policy. If the pre-testing is related to Obesity then these services would also be excluded on the policy." Very discouraging. It's so sad to me that other people that have insurance from BC/BS can get this surgery covered, but because I work there then it is excluded from my policy. This is now considered a disease and it's so sad to me that they just make it sound horrible. "services or supplies related to obesity ..........." Can't they see that it is a disease??? Where do I go from here?

Hi B, Go to BCBS.com and bring up the site and just follow directions and if you have your info to enter in then it should let you pull up the policy and search it for baractric surgery. This should give you all the info you want. Also be aware (cause I'm dealing with this problem now) that when you put in your request for surgery that you put in for the Adjustable Lap Band. Insurance is a sticklier on this...they approved me for gastric by pass cause the girl put that in and I had to resubmitt for the Lap Band. Good Luck and don't give up...Sue

I think it's different for an employee of BCBST. I think it all depends on your group number and the exclusions written for that group. And I really think that sucks. It is your employer who decides what exclusions to apply to your policy. So BCBS itself is my employer and that is an exclusion, unlike people who work for .. example, my mother works for a company that uses BCBS for their insurance. Her employer might put that in the policy of being a covered service. I just think that stinks though for an insurance company to tell me that they won't cover a surgical procedure for a disease that I really can't fight without help. I have tried numerous diets and have failed at all of them. I also have a prolactanoma tumor on my pituitary gland. That causes severe hormone imbalances that I have to be on medication for. The major hormone effected by this is my prolactin levels, and when they are increased it makes my body think I am pregnant, which I'm not, and can you imagine what that does for weight gain? If my body thinks I'm pregnant then it wants to "store" stuff for a baby ........ I just feel like I'm gonna try to battle a wall that won't budge, but I'm not ready to give up. I really have only begun. So I guess I must continue to fight .....