Question:
Anyone have BCBS of TX pay for WLS when your plan has an EXCLUSION????

My sister BCBS of TX and was told that there was in exclusion in her insurance to have WLS. However she also was told that they might cover it IF the surgery was deemed medically necessary for her! So, has anyone had BCBS of TX pay for their WLS with the exclusion in place?    — Chembe (posted on March 14, 2010)

March 14, 2010
I have BCBS of MI and was preapproved for vsg and had surgery in Sept 2009. Now they are refusing to pay because of an exclusion on my policy. The hospital and drs have appealed with no success. I am in process of putting together an appeal also and got info from a patient advocate company in VA to help. I could not afford self pay and would not have had surgery if the drs office had not gotten the preapproval. Of course, there is a disclaimer on the letter stating the preapproval doesn't guarantee payment. Be careful on this one. Check with whoever handles the coverage for your policy (your employer). Hope this helps.
   — Nancy W.

March 15, 2010
I'm interested in what you find out. I too have BCBS of TX and my policy has a very specific exclusion - says it won't pay for any WL treatment even if it will help some other condition... I haven't tried to fight it because it sounds so negative but I'd LOVE to try if it can be fought at all. I have heart disease so it's not just a "might be nice if" kind of condition...
   — boernecheryl

March 16, 2010
BCBS TX will cover these type WLS procedures. Go onto their webise for coverage or contact BCBS TX. Ask for Bariactic surgery Policy # SUR716.003. BCBS Requires a BMI of 40 or greater with no diagnosis or a BMI of 35 or greater with at least 2 diagnosis (ex:diabetes, sleep apnea). BCBS TX requires only 3 months of supervised, documented weight loss (I am seeing a PCP for this). This is to show BCBS that you are at least trying to lose the weight. No matter what weight you do lose during this time, BCBS will go with the "initial BMI and DX" prior to your weight loss. This is good because the more weight you lose prior to your surgery the better it is for you heatlhwise during the surgery. BCBS also requires a nutritional and psychology counseling. This is to be done anytime before the actual surgery. It can be done on at the same time, usually at the same place. BCBS, as I was told, may not cover this procedure, BUt I did get an authorizatin for innetwork provider for my Psy visit. So, BCBS may be willing to do this and the company I am going to is contracted (innet) under BCBS. Otherwise, both of these services only total about $150 and you can just pay this amount out of your pocket. Te Weight loss surgeon will have all the places contact you and get these scheduled for your visit. You will also have to get a cardiac clearance before the surgery Once again, your weight loss surgeon will get this setup for you and they will contact you to schedule. This is done to make sure you are heart healthy to get this procedure done and finally before the surgery, you will need to have a EDG procedure done. The WLS surgeon will usually do this procedure. They place a scope down your throat to be due that all is looking well and to be sure you have no problems. BCBS should cover your cardiac clearance and EDG (minus any copay,coins (out of pocket expense that you may need to meet) or Deductibles you are responsible for. I have had 2 women I work with in my office who had the Sleeve done. One had done in Sept'09 & she has lost 80lbs and the other one had done Oct'09 and she has lost 90lbs. I plan on having my surgery done last May or early June (after the 3mo's required weight loss time). BCBS TX is great and has very little requirements for the WLS. I have no dx with a BMI of 41, so I qualified on my weight alone, 265. Best of luck to you. Also, I do inusrance billing and collections for a living. if you need to know anything regarding BCBS TX insurance and their policys, just let me know and I will be glad to help and try to answer.
   — Healthy10

March 16, 2010
BCBS of MI also covers wls for most patients. However, my policy has a specific exclusion. My policy is self funded and not a traditional policy of BCBS. That is what makes it different. Most people having bcbs in MI are covered. Hope this helps.
   — Nancy W.

March 20, 2010
Thanks Penny!! I sent your reply to my sister!!!
   — Chembe