Jean Elsaesser, hoping to have surgery

I started this process last year. I had some family issues & put possible surgery (bypass) on hold. Since then the my husband's company has renewed the insurance. I went to see my new doctor on Wed. 5/14/03 & they just needed a couple of things to send off to the insurance company(BCBC PPO/Carefirst). I called to ask BCBS some questions & they advised that my husband's company had a Self-Insurred plan through them that they were just administrators & the company had excluded any surgery or treatment of obesity or morbid obesity. They also said any requests put in would be issued a flat denial. My friend told me to go ahead get my paperwork together & put it in anyway. I'm not sure what to do. Can they do that? Even if my PCP deemed if medically needed! I can't even describe how the whole thing makes me feels. I have a BMI of 52, no major helth issues except I'm in pain & out of breath if I walk more than 10ft & can't even keep my house very clean anymore. Why should I have to wait until I have a heart attack? Sorry for rambling.

Jean, I to also am wanting to have surgery. My plan is self insured. I have worked for a self insured company before also....You can go ahead put it in and get a denial and then go up the ladder so to speak to try to get it appoved. Talk to your husbands Human resources department. I am in the same situation and have talked to Human resourses. I have to go before the Board of Trustees of our Self funded health plan to get an exception.....Keep trying do not quit...You may be able to get an exception .....the squeeky wheel gets what it wants.

I am posting an article that I found in Readers Digest. When I tried for surgery in 2000, we had self-funded and of course, I was denied three times. I even tried to file a complaint with the Insurance Commission but when it is self-funded, it is not overseen by the Insurance Commission. This article may give you some information on how to procede with your battle. Good luck!! I still have not been able to have the surgery. Now fighting with another insurance that says they cover obesity in their handbook but when it is fact, it is a totally different story. Sharon You Can Make Them Pay! How to get your health insurers to fork it over! By Peter Lander and Amy Dockser Marcus From the Wall Street Journal From Reader's Digest Elizabeth McKenty wanted a new treatment for fix her congenital heart defect. Her insurer said no. She appealed-and got another no. For most people, that would have been the end. But McKenty, 44, a librarian in Philadelphia, appealed again. With the help of Health Advocate, a company that fights denials, she marshaled medical literature showing why the treatment- implanting a device to help block leakage between the heart's two chambers-would give her better odds than open-heart surgery. This time she won. Most people take it as a maddening fact of life that health insurance companies are programmed to say no, and that appealing only brings headaches and another no. But for all their image as heartless Goliaths, insurance companies aren't invincible. Increasingly, it's possible to challenge a health plan's verdict and prevail. New channels of appeal are making it easier for patients to press their cases. A backlash against health insurers has prompted many states to pass laws setting up external review panels and requiring insurers to adopt in-house appeal procedures. Currently, 41 states and the District of Columbia have independent review boards, most with the power to overrule insurers. Yet only a handful of people are taking advantage of their appeal rights, and many still pay bills they don't have to. The biggest problem is the time and energy it takes to pursue complaints. "A certain percentage are tired, confused, and dealing with a health crisis that doesn't give them the wherewithal to figure this out," says Gerry Martens, a Connecticut state official *****presents consumers in insurance disputes. The chances of winning an appeal, however, are surprisingly good. Nationwide figures aren't available, but a Kaiser Family Foundation review of recent data from New Jersey, Pennsylvania, Arizona, and Rhode Island indicated that patients had, on average, a 48% chance of winning their first in-house appeal. Those who appealed again won at least 50% of the time. Data from 42 states show patients who took the next step-using independent state review boards-won cases an average of 45% of the time. How can you successfully take on your health insurer? Knowing how to navigate the bureaucracy is key. Let's say your insurer has turned down your claim. Most plans have an 800 number for queries, but Rhonda Orin, an attorney at Anderson, Kill, & Olick who specializes in battling insurance companies, says don't call. Instead, write a letter immediately, acknowledging receipt of the denial and stating the grounds as you understand them. Attach medical records, and don't sound angry. Draft a reasoned argument, backed up by evidence, as to why the procedure is medically necessary. If you get a second no, your insurer will likely focus its key reason for refusing coverage. Re-appeal, homing in on the reason for refusing coverage. Get a letter from your doctor-and a second opinion from another physician. Look for articles on the Internet showing the procedure is recognized treatment. If you get a third denial, chances are you'll receive a letter stating, "This is your final appeal." By now, most people will have given up. But if the dollars involved are big enough, it's worth another step. Write another letter, asking if there's anyone else in the company you should talk to. The letter show you've exhausted your internal options, paving the way for going outside litigation or a state board. The Supreme Court ruled recently that consumers have the right to have health plan disputes reviewed by state boards. But most patients are unaware the boards even exist; only about 4,000 people use them each year. The boards are made up of specialists in the area of medicine under dispute. They review medical literature and records from the case, but rarely call witnesses. A decision should come within 60 days or less, depending on the state-much faster if you have an emergency case. The appeal is either free or costs a nominal filing fee. (In many states, the insurer pays for the review while in others, the state covers the cost.) Most states give information about the process on their websites. People who work at companies that have "self-funded" health plans, in which the company directly pays all employee medical costs, aren't eligible to apply to state boards, but they have other protections. (The federal government regulates self-insured plans. The other types of employer-sponsored plan is one in which the employer buys health insurance from an insurance company.) Federal rules require insurers' in-house appeal boards to give judgments in 30-60 days; in urgent cases, within 72 hours. It's also worth checking how Medicare, the government insurance program for the elderly, treats similar cases. Medicare hires private insurance companies to process claims. Its rules influence how insurers act even in non-Medicare cases. Your doctor's billing staff may be able to help gather this information. David Stone, an executive at a Nashville, Tenn., company that handles billing services for doctors, recalls a case in which a woman received two kinds of ultrasound on the same day. The insurer refused to pay for both, but Stone got the decision reversed by showing that Medicare would have covered the two ultrasounds. It's important to start early when dealing with your insurer. Cathie Owen of Kaufman, TX found that out when she was scheduled to give birth to her third child by cesarean section. She wanted a tubal ligation at the same time, but a few days before she went to the hospital, her insurer rejected payment for the ligation, reasoning it was an incidental add-on, known as bundling. Owen, unwilling to foot the $500 bill or undergo additional surgery, kept her tubes untied. If Owen could do it again, she'd insist on getting an answer months before her child was due so she could appeal. She could have explained that the procedure would prevent unwanted pregnancies-therefore additional expenses. Bundling is a common source of disputes. Many insurers use software that automatically chops off some claims for procedures performed on the same day. For example, if a woman visits her gynecologist and gets a regular checkup plus a biopsy, the computer program will allow payment for the biopsy but reject the checkup. The rationale is that a biopsy includes a bit of looking around, so the checkup shouldn't be billed separately. Many doctors fight back by refusing to perform multiple procedures on the same day, instead making patients return on a later day. Doctors are afraid they won't be reimbursed. So if you're on the hook for charges insurance might not cover, the doctor's precaution might save you money, too.

From my very recent experience with BCBS the only way to get around that exclusion is to go through the employer.Sumbit your records to the insurance when you get your denial go to the human resources department and ask them to change the exclusion if that doesnt work each company has a chain of command that you will need to follow in order to have the exclusion changed,but Im sorry to say that if the employer wont change it fighting the insurance company over it will not work.Make sure you stay on top of the human resources deopt though because if you have a lazy person in there NOTHING will get done(just went through that too but thats another LONG story)Good Luck!