Question/BCBS of Alabama PPO

Hi all of you insurance guru's! Let me tell you a little about my journey thus far. I found out about the lap band procedure about a month ago. I did lots of research on it and decided that it was for me. Before even looking for a surgeon, I called my insurance company and spoke with a lady who said that my plan covered WLS with no exclusions. I told her that I was planning on having the lap band surgery and she said it shouldn't be a problem since there were no exclusions on my policy. So I searched for a surgeon in my area who would perform lap band procedure and the closest on I found was Dr King in Oxford, Mississippi with Liv-Lite. I called Liv Lite and spoke to Lacy and she took my insurance information and I made it very clear to her that I was having the lap band procedure. She called me back the next week and left a message telling me that insurance was verified for the gastric bypass. I called her back and told her I was NOT having gastric bypass, but that I was having lap band and she acted like it was no big deal and took my medical history information. She told me that I would hear back in 2-4 weeks. This was on October 6. So yesterday (10/18), I got a pamphlet in the mail from Liv Lite, just explaining their program and such, so I decided to log on to their website. There, I saw that there was a facility in Decatur, AL, which is about 3 hours closer to me than Oxford, so I decided to call and see if they had a dr who would perform lap band. I talked to a different lady on the phone this time, and she told me that Decatur did not have a physician who would do this procedure. Then she asked me what insurance I had and I told her BCBS of Alabama PPO. She said, "Oh, they NEVER cover lap band surgery." WHAT! So I hang up with her and decide to email BC and just see what they said about it. The policy is under my husband's name, so I emailed them as my husband. Here is that email... "My wife is planning to have Adjustable Gastric Banding, aka Lap Band. Today she spoke with Liv Lite of MS (Dr. King's office) and they now say that BCBS of AL doesn't cover lap band ever. When she spoke with BCBS before ever speaking with any doctor, they said that there were no exclusions on my plan. Is this true that this procedure is NEVER covered by BCBS? Thanks." Reply as follows... "That is correct. The information submitted to us by the provider did not include the procedure code for the surgery. However, the Lap Band procedure is considered investigational and not covered under any of the Blue Cross and Blue Shield of Alabama contracts. Sincerely, Tracy Customer Service" Any thoughts or ideas of what to do? Shouldn't it be an exclusion if it's not covered? Thanks for your help! Shannon

You will probably get a denial letter from BCBS stating that the Lap Band is not covered due to an exclusion for Experimental or Investigational Procedures. Most of the insurance carriers are trying to exclude Lap Band under this exclusion, and continue to pay for RNY. The most recent data I've read (this week) states although Lap Band is safer, RNY is more effective in the percentage of weight loss reached and maintained. However, at least 3 of the Blue's have come around and are now allowing the Band again. (Texas, and two other states that have slipped my mind at the moment.) If you haven't already, check out the Yahoo group for Bandsters. I'm sure you will get some great info there.

I have the same question as you, I have BCBS of Alabama. They have told me also that it is invesigational. So I am wondering what to do too. I am thinking about fighting it. Good luck to you, if I find out anything I will post it here on this board.