Ins. question

I have a friend in TN that has Anthem of blue cross blue shield insurance and she has an exclusion on her policy: the following is excluded "For bariatric surgery, regradless of the purpose it is > proposed or performed. This includes but not limited to Roux-en-Y, > Laparoscopic gastric bypass surgery or other gastric bypass surgery ( > surgical procedures that reduce stomach capacity and divert partially > digested food from the duodenum to the jejunum, the section of the small > intestine extending from the duodenum), or Gastroplasty, ( surgical > procedures that decrease the size of the stomach ), or gastric banding > procedures." Has anyone had any luck getting this approved or is it solid. Any adice to pass to her would be appreciated....

Hi Kristie. If it is an excluded procedure, then it will not be approved. Even if it is medically necessary and dr recommended. I do not think it can be overturned. The only way is probably through her employer. They only thing I can say is to try. Go through the steps of getting approval and when they deny, appeal it. And appeal it agian until it goes to the board and see if you can it approved that way. Other than that, maybe have it submitted the first time with the help of an attorney. The site http://www.obesitylawyers.com/sub/index.jsp?contentid=ZBLbLrvgmLH4u7S34pMFQKcI says that they can overturn exclusions if they are there to ask for approval the first time. I think there are options and no matter what, do not stop fighting or trying to have surgery with or without insurance if it is something that your friend needs and has made up her mind to too. Good luck Misty

It's pretty solid if it is specifically excluded. She will have to work with the HR department of her employer. The insurance company itself isn't who is responsible for the exclusion, it's the employer (a lot of people don't know that). If she can make the case with the HR manager, she may be able to get an exception to the exclusion through them. Good luck and have her utilize the links in the other reply to your post, they should be good resources also. Toni

Hi, I have only heard of one person in Knoxville that took it to the court because of an exclusion, and won the right to have the gastric bypass. Best of luck to your friend, Kathy