Insurance - Please help

I received a letter yesterday from BC/BS of Missouri, in response to my request in Jan. for approval of gastric bypass. I'm confused more than ever. It read: Based on the medical info. provided to us, the services are not covered under the patient's plan. The plan excludes various services from coverage. Since our member's health benefit plandoes not require prior approval of benefits for requested services, THIS IS NOT A DENIAL OF BENEFITS. If our member decides to go ahead with the services and a claim is sent to us, we will determine eligibility for benefits at that time, based on the provisions of our member's plan and our guidelines for coverage. If we then determine that the services were medically necessary and were covered, we will provide benefits. Does anyone know whats going on here. From what I see, it looks like they are telling me to go ahead, but I am confused. Any Ideas? Thanks Paulette

Before you proceed, I would call to ask exactly what the insurance company meant for the letter to mean. It sort of sounds to me like they are saying your doctor didn't submit enough information about why you need a bypass. I would think that if you proceed with the bypass without anything else from your insurance company, you are risking them denying benefits after the fact and you being responsible for the whole surgery. Of course, I could be wrong! Good luck!

"Based on the medical info. provided to us, the services are not covered under the patient's plan. The plan excludes various services from coverage." This means that benefits for WLS (treatment of obesity) is an exclusion under your plan. HOWEVER, never believe anything that an insurance company tells you, even if it's in writing. There is a good chance that they made an error, and an equal possibility that they didn't. You MUST read your Summary Plan Description Benefit Plan Booklet carefully. Look under EXCLUSIONS or BENEFITS NOT COVERED to see if there is any mention of treatment for weight loss or obesity. Make sure you have a copy of the coverage in effect. If it's an old booklet, get a new one.

Send them documentation of any comorbidities again, and as many other doctors etc statements as you can as to medical necessity. My insurance BCBS approved me then later sent me a letter with approval letter which stated it was not a guarantee to pay and a bunch of BS. I plan to go ahead, because I know it is NOT an exclusion on my plan if you have a BMI of 40 or more, or 35 with comorbidities...... I am over 40 and have comorbidities. In addition, I went for pulmonologist approval after the original paperwork and that Dr. says my symptons show that GERD is putting acid into my lungs and causing respiratory problems. He cleared me, and put me on medicine to help, which it did. The insurance would only fill 1/2 a month of GERD medicine at a time........ so I went back to pharmacy in two weeks and filled it again. It is all a game to insurance co to get out of paying..... if they can fool you into giving up. The pulmonologist said I probably don't have sleep apnea & set me up with a Sleep DR. just in case. I went there today, and he questioned me and examined me and he says... I have sleep apnea (of course my husband had confirmed that before the appt date came up). Now I am going for a sleep test. These were comorbidities that I would have never said I had...... GERD yes, but not as severe as pulmonologist said, and his medicine started an immediate improvement in burning in my lungs. So if you have not done some of the tests go forward and submit paperwork again with all new reports included. If they are just trying to get rid of you, they will decide that you aren't going to give up. I had let the ins. co. beat me on the GERD medicine for 3 years and in that 3 years my lung function was terrible. It ended up costing them for 4 extra prescriptions that are way more expensive.