what company do you work for that covered your surgery

Hi,
I am still fighting to have the bypass.  We have Highmark BC BS.  while i followed their guidelines, once i had my appt. with the doctor i was told it was not in our benefits package.  HR told me to appeal to Highmark.  I did.  It was denied bc "although appropriate and medically necessary" it was not "in my plan".  THey said to do a second appeal.  Again it was held up becuase it isn't in my plan.  I then went to the HR at my husband's office.  THe benefits lady basically said it is a dangerous surgery, you are doing it to just lose weight and it will put the weight on.  And "i don't know of any company that covers it".

So once i got over my initial shock.  I wanted to ask anyone who had it done, what company they work for, what insurance the company used.  And, if you live in NJ that would be a plus too. 

Thanks again.  I think i can convince her if i have more ammunition.

Catherine

I had the lapband surgery but there is a few people I work with that have had RNY and it was covered.  I had NJ Plus at the time of my surgery and now have NJ Direct and they cover my fills.
The other girl had Aetna.  I work for the State of NJ and they offer several differnt plans.  Also when I had my surgery the doctor's office did all the leg work with the insurance company as far as writing a letter and had my primary doctor copy on his letterhead. I would check with your HR dept and see if there are other insurance options.  We have open enrollment every November and can change if we choose to.  Good luck, also tell them it could be more dangerous to carry all the extra weight around you are subject to more life threatening problems. ( Heart attacks, diabeties, etc)

THanks I appreciate it.  I found a lot of State plans cover it.  as for other options, there is only one. 

Verizon covers all four wls types, but not out of area such as omaha, they are a east coast company, so you have to have thier MCN not the mcp plan,

Catherine,

If you did two appeals, DON'T GO FOR ANOTHER ONE. If you do 3 appeals, and they deny you - YOU'RE DONE FOR GOOD. Unless you get another insurance company.

What you want to do is two things (1) Speak to supervisor at Highmark and get EXACTLY what is and isn't in your plan. Denote their name (or ID), the time you called, and what they said. READ BACK to the person what you believe they are staying to you to make sure you have not misheard the information (2) Get a lawyer. There are plenty on this site which can help you make sure you don't get the run around, denied, and can be approved (if that what the supervisor tell you).  

HI Tom,

I love reading your posts.  YOu are so knowledgeable about this whole experience. 

At this point i am not fighting the insurance company.  It is up to my husband's job.  It always has been.  It isn't in my plan.  Period.  That was why it was denied twice... "not in your benefits package"..   Only HR can decide to cover it ... they are self-pay.  The external review is set.  If based on my doctors' notes, and other info i have sent (plus my endocrinologist is really putting up a fight for me), Highmarks' medical board agrees to the medical necessity of it..which they stated that it was in my 2 denial letters... then Cookson (my hubby's company) has to pay for it. 

 I truly do believe they will cover it.  I think they just want to make sure i jump thru all the possible hoops. 

I am going to keep all my crossable parts crossed and hope that all of the information i provided them and the numerous specialist notes and the second packet my endo is sending.  she is at the point too where she is citing journal articles and closing with "she will not be held responsible should anything happen to me if they don't agree to the surgery"  or somthing to that end. 

Thanks again.

Have a fabulous weekend.

I just recently had gastric sleeve surgery on May 9th and I live in NJ.  I work for the Hartford Insurance Company and my medical insurance is through BCBS, and they definitely cover the sleeve, RNY, and lapband that I know of.

HI Tom,

I spoke with the PA Insurance Board and yes, i have to do the external appeal (which will be denied as they are still with Highmark).  THey cannot tell COokson (the company ) to pay.  I mean i guess they could but won't.  Then i can appeal to the HR dept.  

My question to you as you seem incredibly knowledgeable here,  i finally was able to get the PPO agreement and there are some "gray areas".

Do you know of any cases that "bariatric surgery is required by law"?  

Do you know of local NJ attorneys who deal with Bariatric Appeals or where to find one?

Thanks again
Catherine

I am on travel and answering via my phone so please excuse the brief reply

I don't think my law they can force a company

I don't personally know lawyers but my Dr practice does and some are former patients. You may want to ask your Doctor

I know of a private insurance that can help but of course it will be out of pockets payments. Maybe they can suggest a good lawyer.

I can answer better on friday when I get home

thanks.  I appreciate it.  Safe trip