Has anyone got BC/BS PPO for MA. ????

I am looking for anyone who may of been approved with this insurance . They have said they do not cover this but from every thing I have read No may not mean NO. I am looking for any info that I can get. I meet with my Dr. for consultation next month and I want to go in with as much info as possible . If this does become an issue I want to at least be prepared and go right into the next step. Please any info would be greatly appreciated

It depends on the policy.  If it is an individual policy, lacking a state mandate, it is a safe bet that no means no.  If it is an employer based policy there are 2 types of denials.

A coverage denial means your employer did not purchase the coverage.  It may or may not have been an option (might have depended on group size - I'm not familar with MA), but if there is no coverage, there is no coverage.

A medical necessity/experimental/investigational denial is different.  That is where no may mean maybe :)

http://www.bluecrossma.com/common/en_US/medical_policies/379 _Medical_and_Surgical_Management_of_Obesity_including_Anorex iants_%20prn.pdf#page=2

Looks like if it is covered, they will cover, VGB, RNY, and Band.  They will also cover the DS for those with BMI of 50+ who have not responded to conservative measures.  If they deny one of these services due to medical necessity, you *may* get the decision overturned by appealing (usually with additional information).

They specifically exclude the sleeve procedure (plus lots of others) as experimental/investigational.  If you want one of these procedures it will be much harder.  Your surgeon *can* appeal, but it is much harder since you have to justify the procedure itself, not just the patient meets the criteria if that makes sense.

Of course if your employer is a self-funded large account, it is easier since they can override the denial (but there could be issues here - in general they are required to treat all similarily situated employees the same, so if they would approve for person A, they would have to approve it for person B if they had similar conditions etc).

Good Luck.

Thank you for answering my question and the Web site was very helpful.  I have dug around some and made some phone calls and to be honest these people confuse the hell out of me . The first time I called them they said I was covered but I started studying my policy and it has exclusions on  WLS .So I called again to verify and they now claim they do not cover it . The reading on the exclusion kinda leaves me ???? I guess my best bet is just let it play out and then take it form there.
                                  
                           

 
I suppose it depends on your plan.  I was recently approved for RnY within 2 weeks.  BCBSMA PPO.  I have a 48BMI, sleep apnea, and hypertension.  Did not need to do 6-month supervised diet, or many of the hoops other here seem to have to go through.