Exclusion question

Hey all,

   My Insurance is BCBS PPO state employees of Florida. My specific plan has a weight loss assistance exclusion. However I've been told if deemed a medical necessity that it could be over turned. Right now at this specific time I am 302 lbs, 5'4 (or 5'3.5), High cholesterol, high tricglcerides, border line diabetic (current sugar 286), Polycycstic ovarian syndrome, weak knees and ankles and sometimes shortness of breath. I haven't even has a period in 12 months. Ughhh. OH and I'm only 27 years old, plus I'm a cop and can barely do my job, and its a major safetly issue for me and my partners.

So I guess what I'm asking is, does anyone have advice on this. My surgeons office submitted my paperwork for approval to my insurance company on Friday. I'm really scared. My surgeon is Dr. Gagner and he said its a medical necessity and does not see how they could deny, but we all know how that goes.

  Thanks in advance for you responses, Tiffany

If it says you can have WLS if medically nessicary I dont see how they could deny you!

But if there is an exclusion for WLS then they will for sure.


Good luck!

The words say unless it a medical necessity. However the policy was updated I think on Oct. 1st. So as far as after Oct. 1 I don't know... who knows maybe I am screwed...

I  have BCBSNC State PPO (government worker) If your insurance is like mine, they only want to pay for RNY. I am fighting for VSG. Haven't gotten my first denial yet but I am sure it is coming. I will be blowing the insurance board up looking for help. Good Luck to you!!

I have BCBSF PPO - I have submitted the VPCR (Voluntary Pre-Coverage Review) twice.  The first time, I didnt have a letter of medical necessity, but the second time, I did.  I havent received the letter yet, but I called the customer service # 2 days ago, and they told me it had been denied.  The 'Medical Necessity' card is the one I'm playing now, and though it gets SO FRUSTRATING at times, I am constantly doing research online to see if there is another angle I can go at them with.  They WANT you to give up.  Perserverance is bound to pay off.  Let me know how things progress with you.

Kelly

Tea do you have the capability to look at your benfits online and if so can you copy and paste it and maybe let me look at it as I can interpret the policy for you for sure.   I have the experience 30 years to be exact.  I am willing to help you.

Vicki

Get the exact wording of the exclusion. If your employer has excluded WLS from your policy, medical necessity won't help, but if the exclusion isn't that specific, it might. Who told you it would--was it something you heard on here, from your HR office, or from your insurance company?

On an unrelated note, if your sugar is 286, you aren't "borderline" anything--normal non-diabetics do not go above 140.