HORIZON BC/BS NOT COVERING ROUX EN Y!!!!!!!!!!

I WENT TO SEE ANOTHER SURGEON THE OTHER DAY AND HIS STAFF INFORMED ME THAT HORIZON BC/BS WILL NO LONGER PAY FOR SURGERY FOR PATIENTS WITH A BMI OVER 60. THEY CALL IT "INVESTIGATIONAL". THIS IS BULL%&#!!!

JUST WONDERING IF ANYONE ELSE HAS RUN INTO THIS LOVELY LITTLE LOOPHOLE LATELY?

 

ypur best bet is to keep after them letters doctors letters dont give up good luck

Dont give up, there must be a loop hole somewhere. Maybe other options? Another procedure maybe that they will pay for. Keep asking and writting letters. Good Luck.

Did you check with your employer?  Usually as long as they don't specifically exclude it you should be ok.  You may have to fight for it and keep after them to get approval but it's well worth it in the end.

I have had multiple friends who have had their surgery post poned for that exact reason.  It's all of BC/BS, not just NJ. The way they got around it was to lose just enough weight (temporarily for most) to be under 60 when the letter is submitted.  Not an easy task by ANY means, I realize.  Hence why the surgery is needed, because losing weight is so difficult for us. I don't know about other surgeries, but you could look into them and see what BC/BS covers.  DS and banding for example. Best of luck and keep us updated. Pam

I have Horizon, too.  At the time I first met with my surgeon my BMI was 62.9.  I had to do a 6 month supervised diet and lost 35 lbs so at the time we submitted my final info, I was under 60.  They did not say anything initially, though, about my BMI being too high.  Are you much above 60?  I know it is disappointing.   Jenn

I had my surgery under BC/BS and at first they were not covering RNY and it was because of the procedure code . The Dr. used the Long loop code and actually another dr I went to used a different procedure code for the same surgery and it was not longer investigational and it was covered.. Check on the procedure codes .. you may need a different dr.. The dr I went to was indignent about changing the codes. So I found another dr.  Good Luck

I had the same thing happen to me. About a year and a half ago, I tried for and got approval very easily with no problems within one week. I had to postpone surgery for a variety of non-health reasons and when I went to reapply for coverage, one of the reasons they gave me for not approving me was that my BMI was over 60 and it was therefore "experimental." What B.S. I refuse to give up, but it gets very frustrating jumping through all of these ridiculous hoops AGAIN. 

yup!!!! they did the same to me!!!! it sucked... u wouldnt believe watt i had to do to gett approved.. .they're going to make u lose weight!!! like come on now if u could lose the weight dont u think u wouldnt be gettin surgery!!!!!! sheesh!!!