Anthem Grievance Hearing

Hello, all... I have been "invited" to an Anthem BC/BS grievance hearing this coming Friday, at which I can present my case in hopes that they will reverse their original denial for my WLS. I'm wondering if anyone has had any experience with this sort of thing. I've written appeal letters, but presenting in person is a whole new, nervewracking experience. Any help or suggestions you have would be great! Here's what I'm dealing with - 1. Initial claim was denied based on plan exclusions, not medical eligibility for WLS. 2. Medical necessity has been proved and documented according to Anthem's own medical policies. 3. BC/BS is citing "exclusion of weight loss programs" as the basis for the denial, but WLS isn't a weight loss program - it is a medically necessary surgery. 4. In reality, there is no exclusion for WLS because many people working for my employer have received WLS and have had it covered - one with my same surgeon! Thanks!! Sara

Sara I hope things went well for you and that they decided in your favor... But just an FYI you cited that several other employees had the surgery that worked for your employer... what you may not be aware of is they may have had insurance through another employer ie on their spouse's plan or have a secondary plan that does cover this surgery. Also Employers can and do revise the benefit plan... in 2004 my employer covered WLS but  when the submitted the renewed plan for 2005 they excluded WLS, only to added it back to the benefit plan in 2006..... So even if the plan currently excludes WLS... does not mean it will always exclude it... and the reverse is true Iit is really hard to get the employer to agree to a benefit exculsion and that is what you are trying to do.. for reasons only known to  the employer who purchased the  group insurance plan they elected not to cover WLS for the  year of 2006...Benefit exceptions can be done but they are rare and hard to do..... I  hope you got your decision and that it went in your favor. If it did not, then  you have a couple of options open to you... check out your spouse plan.. if they cover WLS you can  opt to be covered under your spouses plan and drop the coverage with your employer.  Or you could look to change to an employer who does provide WLS coverage, and last you can  find alternative financing. Use the last option carefully many plans that exclude WLS also will not cover any complication that can occur as a result of WLS and this can get costly good luck