BCBS denied my request for a case manager!!!

I called BCBS this morning to request a case manager be assigned to me to help me. My policy states: "Under the case management program, the plan will identify members w/potentially complicated medical needs, chronic illness and/or catastrophic illnesses or injuries that may be suited for alternative treatment plans. After evaluation of the member's condition, the plan may, at it's sole discretion, determine that alternative treatment is MEDICALLY NECESSARY and APPROPRIATE. In that event, notwithstanding any provision of this EOC to the contrary, the plan may elect to offer alternative benefits for services NOT OTHERWISE SPECIFIED AS COVERED SERVICES." Well, BCBS said they could not assign me a case manager because obesity is not a covered benefit in my plan (exclusion)!!! Does that make any sense to y'all? I am so frustrated with BCBS. I thought it was my right to have a case manager assigned to me? Anyone else have this happen to them? Tammy

Tammy, In most cases "obesity" is not a covered benefit. However "morbid obesity" can be a covered benefit. Make sure there is that distinction and good luck. I don't use BCBS but I've heard they can be difficult to work with. Toni

Hi Toni. The exclusion on my plan is for morbid obesity too. I may try to request a case manager based on my comorbid conditions and not mention the "morbid obesity" and see what happens. Tammy

Hi Tammy, My husband's employer has BCBS/TN with an exclusion for obesity also. We submitted documentation from doctor with appeal letter and stressed "morbid". At first we had hope because claim dept called and asked for doctor to submit predetermination with more info and said since employer's policy hadn't been updated to exclude "morbid obesity" it may be covered based on morbid. However, two appeals later and still was denied. But, we didn't talk to Gary so I'm sure he can help you fight them. Fortunately for me, I was able to get insurance from my employer in 2005 that does cover WLS. If your insurance is an employer paid plan, I would check with your HR dept to see if they will have the WLS exclusion removed. BCBS/TN told me that for employer plans the employer chooses and their basic insurance plan has an exclusion for all WLS (they have plans they do pay for WLS). When I was searching the insurance forum, I remember reading that some with BCBS (not necessarily TN) has success in dealing with their HR dept at the employer to have exclusion removed. Best of luck to you!!!

Hi Stephanie, Thank u for responding to my post. I am going to call Gary and talk to him about this situation. When he spoke to my husband he mentioned something about "discrimination" so I want to find out more about that. I am also going to wait a few days and then call BCBS back and again ask for a case manager to be assigned to me based on all of my comorbid conditions. Keep your fingers crossed for me. I am glad everything worked out for your husband. If all else fails, I will try to find another job with better insurance that will cover WLS! Tammy