Question:
How do I get my insurance provider to change its policy of excluding ANY WLS?

I am in the process of investigating WLS but have just learned that my insurance provider, Anthem BCBS PPO in Richmond, Virginia, does not cover any type of weight loss surgery. Is there a way to get around this exclusion or get the provider to change its policy? Robin from Richmond    — Richmond_Robin (posted on November 4, 2008)

November 4, 2008
Well, I've tried that with RegenceBCBS PPO in Utah for almost a year....with no success. They kept telling me that I had a group contract (from work) and as long as my employer would keep that contract, I would not be covered for any WLS. I then asked if I could subscribe on my own and they answered that WLS coverage was only offered to group contracts. The only way, would have been to have the whole company switch to another kind of contract, and then oblige each employee to pay get more expensive policy.... I couldn't decently do that...so I paid myself, went to Mexico to pay less and only regret I lost all that time with this insurance! Of course, it's different with each contract and I don't know the differences between Regence and Anthem, but going around a contract you already have is not easy. Anyway, I do hope you'll make it. Good luck!!! PS: I learned afterwards, that very large companies have usually automatically the WLS coverage included in their group contracts, and if not, thet can add it for cheap.
   — ghis31

November 4, 2008
Sorry but I work in the ins. department for my company and unless you change your plan you can't get around the exclusion. See if there are other plans that your employer can offer you, such as an HMO this way your primary can refer you and you might have better luck this way.
   — CLAUDIA J.

November 4, 2008
Robin, This is not an Anthem exclusion. Anthem Medical Policy SURG.00024 descibes what is / not covered. Here is the url: http://www.anthem.com/medicalpolicies/policies/mp_pw_a053317.htm Talk to your HR department to find out why your employer chose to exclude this procedure. Best of luck!!
   — nursenut

November 4, 2008
Hi Robin, Is the surgery excluded or excluded/not covered unless medically necessary? There's a difference so if you're not sure, give the insurance company a call and find out. If it's out right excluded then no there is no way around it. If it's excluded/not covered unless medically necessary than there is a possibility of having it covered but you will need to prove your case by having your doctors and surgeon submit your medical documentation to show necessity. As far as the insurance company changing it's policy on coverage for it if it's excluded?? I'm sorry but that's not going to happen. Insurance companies will not just change contract stipulations because a member needs coverage for a certain surgery/procedure etc. They're legally bound to the contract just as your employer is and besides that, it's not the insurance company as a whole denying the coverage, it's the specific contract your employer purchased from them. Every policy within the insurance company is different as to what it covers and what it does not cover and that is determined by what your employer chooses. Of course, your employer has the option of upgrading the benefits to include WLS coverage but I can tell you that in the 10+ years I spent with Horizon BCBS, I never once saw this happen and it's usually because the rates they will have to pay will skyrocket. It's basically the same reason, the employer chooses not to include infertility benefits on the plan. I'd say the first step is to find out for certain the type of exclusion the plan has and then take it from there. Good luck. Valerie
   — [Deactivated Member]

November 4, 2008
I am feeling you friend, I had BCBS of FL and all WLS was an absolute plan exclusion, no exceptions when I had LapBand surgery in '06. I was a self pay... about $18,500 total... a great investment in my future. One good thing about self pay is, the process works very quickly as there are no hoops to jump through and you get your date of surgery very quick. Kinda nice, just expensive. Would do it all over again. Dawn Vickers
   — DawnVic

November 5, 2008
It is not the insurance company, but the group plan of your provider. You may speak to your provider and ask them to offer you a plan that does cover weight loss surgery. That is what I did with Anthem BC California.
   — SharonZ