please help BCBS of TN Exclusion

My first time posting.  I have BCBS of TN with the dreaded exclusion.  I have spoken with the surgeons office  and the insurance with little encouragement to getting around it.  I have also talked with my employer and they are behind me 100% and would like to help.  Our insurance tells us there is NO WAY of getting around it.  My boss is willing to help in just about any way, other than just handing the money over to me to get the surgery. Please if any one has any suggestions let me know.  My husband and I are talking about coming up with the money another way if we have to.  We have a beautiful 3 y/o adopted son and I'm scared without this surgery I'll never see him grown.

If your employer is behind you 100%, then that's where you need to start.  Check to see if they can alter the insurance plan they've contracted with.  If the exclusion can be removed from the policy, then you're in business --- and often it's just that easy. If the exclusion is put in place by BCBS of TN itself (and not dictated by which policy contract the employer has chosen) then there's not much you can do.  At least that's the way I understand it from what I've read here. Maybe there's someone with more direct experience from TN specifically??? Pam

It is a BCBS exclusion.   They are telling me they don't even offer a plan that covers it unless the company is self funded.

They are contradicting themselves....they don't offer a plan that covers it unless a company is selfpay...so they DO offer a plan that covers it....find out how your company can get that plan...become self pay whatever.  Do you work for a large company that has a HR department? Talk with the benefits person... BCBS in many states has been covering WLS....maybe been a pain to deal with but at least has been willing to say they cover it...and given the hoops to jump through. Get the plan documents...all of them....

BCBS is definately a pain to deal with.  My company has been VERY supportive.  We only have aprox  130 employees and I work closely with our HR director (she is one of my best friends). 

I am including a direct quote from our insurance group that they sent our HR concerning gastric bypass:

"BCBST does not have any official wording on why they exclude gastric bypass from their fully insured contract, but I would think it has something to do with costs-both initial and follow up due to complications.  Though the initial cost of the procedure can be $20,000-$35,000, the follow up due to complications (sometimes life threatening) can sost over $100,000."

He goes on to say, "I have not found any fully insured carriers in Middle Tennessee that cover the cost of the procedure or complications from the procedure." Any suggestions from here?  Anybody?

This is what I found on BCBS of TN's website regarding surgery for morbid obesity.  I don't know what exact policy you have or if you have one of the policies they say doesn't cover this, but it looks like the do offer coverage for bariatric surgery.  You might want to investigate this further.   I had my policy in hand when my surgeon's office called my insurance co (BCBS of AL), so I knew I had coverage..however they told my surgeon's office that it was not covered.  I told the surgeon's office that I was looking right at the policy and it was covered...they called back and sure enough, BCBS said "oh yeah, I guess we do cover it."  Make sure that you get a copy of YOUR policy in writing before you give up on getting them to cover it.  Or...they exclusion may really be on your employer's end and they just don't realize it. http://www.bcbst.com/MPManual/Bariatric_Surgery_for_Morbid_O besity.htm

The Insurance is BCBS PPO of TN.   Policy reads: This EOC does not provide benefits for the following services, supplies or charges:  Services or supplies related to obesity, including surgical or other treatment of morbid obesity. Again, the Insurance is telling us this can't be lifted not even when it's time to renew and that no insurance company in middle TN will cover it unless they are self funded.

Who is your financial counselor?  I too am using Dr. Houston and Tonya is my counselor...she is know for being a fighter for all her patients and goes to war so to speak if she has to.   I am sure they are all like this as well but I have been told, unofficially of course, that if you medically need this, it can be done...don't give up!  Also, email Gary Viscio...he may have some suggestions.

Hey, I was reading through some other posts and found this one...check it out. Post Date: 9/27/06 4:45 pm Hello Tonja I got denied twice and today I had my second level of appeal and they seem to be trying to show me which way to go. They thought me that they have an exclusion for obesity treatment but if the word obesity is not used and your doctor requests that the surgery is for treating your sleep apnea or high blood pressure or asthma or something like that that they will consider it and most likely approve me because it will be medically necessary(your Dr. needs to say that) and it is the most effective treatment for all of your conditions.

Thanks so much for the info.  Some of the best advice I've heard.  I too have been speaking with Tonya @ Dr. Houston's office.  I have not started submitting all my information until I've learned more what to expect from BCBS.  Our HR girl went to a BCBS seminar today so I'm hoping she finds out something. I'm a nurse and have pre-certed many procedures, but I have never in my life run into so much run around as WLS. By the way, Congrats on your approval.