Question:
Dealing with exclusions?

I am pretty new to this insurance tango, though I've been reading through some of the other members' stories and it can be both heartening and discouraging! I've already been for an initial consult with Dr. Hamad (Magee Women's Hospital, Pittsburgh) - yesterday, actually. The office's insurance coordinator called today to inform me that my insurance does in fact exclude bariatric surgery. The provider is Anthem BC/BS Blue Access PPO. I looked up the exclusion on their website in my health benefits section. It reads: (Exclusion #28) "For bariatric surgery, regardless of the purpose it is proposed or performed. This includes but is not limited to Roux-en-Y (RNY), 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 decreases the size of the stomach), or gastric banding procedures;" Where do I go from here? Am I up against a brick wall? Any and all help would be greatly appreciated.    — Kate B. (posted on May 11, 2006)

May 11, 2006
Kate you don't say how overweight you are- what is your BMI? Do you have other co-morbidities? If your BMI is at least 40 and you have co-morbidities then get ready for some work to convince the insurance how this will not only benefit you but them in the long run. Enlist the help of your doctor- you will need to present in a matter of fact way what the progression of the co-morbidities will likely cost the insurance company in the future and how having this surgery will cut those costs as well as improve your health. Lastly- check out the Medicare/Medicaid (CMS) website- the Feds just approved WLS - without the need for the 6 month diet trial- you can use the Feds decision to cover this as another pressure point on BCBS- also if memory serves me there is either a website here at OH or at least a referral for legal help to try to get the insurance to cover it. Good luck!
   — dabby

May 11, 2006
When I initially checked with my ins co as to whether gastric byapss was covered, I got a great big NO. A few months later I was looking into the lap band procedure and I got an initial yes. The Dr's office called to get approval on the second go around and I think there is something to that. They say that you can check one month and the answer can be no, then the next month the ins co could decide to cover it. It is frustrating. I would let the Dr office do the inquiring. The other thing the Dr office did was have me get letters of neccessity from any Dr. office I had been in contact with so I would have my ammunition from the first. That helped a lot. I got my lap RNY Tuesday morning. Good luck! Linda K
   — lkirshstein

May 12, 2006
Kate I had a situation the same. What I had to do was wait until Open enrollment of the next year and change insurance providers. This might help. Do your homework before you pick the next insurance provider.
   — feleciaj1

May 13, 2006
My ins had an exclusion too and after months of failure I have resorted to self-pay. It makes the whole process much easier, but obviously it's very expensive. I'm refinancing my home. I hope it will be worth it. Good luck to you. Jenn
   — Jennifer V.