Anyone ever fight a written exclusion? BCBS FL

Hello,

Anyone ever fight a written exclusion to cover WLS? It is not and employer based exclusion just a general policy one.

Is it even worth fighting it? Could it be appealed and over turned with enough proof of medical necessity?

Thanks in advance.

I don't think that it is worth fighting, although if you do fight it, the worst that can happen is that they say no (and you spend time and possibly money).  If the employer excluded it, it is excluded, and the insurance company has no obligation to cover it.  Look to see if there are state laws regarding whether it must be included.  Alternatively, you can seek out an attorney who specializes in this to see if you have any rights.

Good luck!

Based on what I have learned in my insurance quest, once thing**** the independent review process, you're evaluated on the basis of medical necessity, not insurance coverage. My recommendation is to invest the time in talking to someone experienced in the area and see what they say. From what I understand, it's a tough road to go, but I think some people have overcome their exclusions.

It is not worth trying. Your clause states it will not cover anything that has to do with weight loss except what they will allow (discount to a gym). So any time you go to a doctor, you can not discuss it on the off chance they use a weight loss code to file and then you are left paying the doctor bill in full. I met with a weight loss doc who was all ready for me to get the surgery until his office called BCBSTX and was told they cover nothing to do with weight loss for my contract. I cried, I worked hard to get to a better job to get better insurance and benefits so that I could attempt weight loss surgery to be told nope there is a clause. I took my 9 year old for a flu shot and because the doc discussed his weight, the doc office coded the visit as weight loss and not a flu shot. I got a lovely bill for almost $200 because my 5 ft 9 year old that wears a men size 8 shoe is actually over weight. I went through a month of fighting just to get that visit refiled correctly.