Question:
I have BCBC (point of service) they have a written exclusion for weight loss surgery

I was told to self pay and then send in claims. They said they would be denied, then I would appeal. Has anyone gotten this type of insurance to change their mind and pay?    — juanita F. (posted on September 24, 2003)

September 24, 2003
It is very hard if not near impossible to get written exclusions overturned. You could be stuck with a huge bill.
   — Delores S.

September 24, 2003
I'm in one of the BCBS plans. I initiately thought I wasn't covered either. Ask the customer service rep specifically what cover you have if the diagnosis code for morbidly obese is used. In my case, that was the exception to the exception.
   — rleffler

September 24, 2003
I had BCBS and they had a written exclusion and absolutely WOULD NOT budge no matter what I done. Sorry.... I wish you luck.
   — CARLA C.

September 24, 2003
It is unusual that the BCBS POS plans would have the exclusion if MO. The POS plans are the most expensive and those usually cover it. Get out your insurance booklet and look in the exclusions section. There will be an item that addresses weight loss programs etc. not being covered except in the case of MO and disease etiology. If it reads like this, and you qualify by the NIH guidelines, then it is likely your ace in the hole. If it does read this way then you can get a pre-auth foer the surgery. Doesn't guarantee you they will pay every last penny, but it will be a covered procedure. You might get hit with UCR charges, but still way less than paying for the whole thing. All of my providers did not have contracts with BCBS and all I ended up paying, above my deductible and copy, was $101 of my anesthesia bill, out of $26,000+ of charges. <p>Regarless of what anyone told you over the phone have your surgeon submit a pre-auth letter with the proper procedure code and a diagnosis code of MO. Let then deny it in writing! Make sure to include a detailed diet history, which can be put together by you, and have the surgeon address your most serious co-morbs. <p>If indeed there is a clear written exclusion then it's not worth your time to fight with BCBS as they won't budge. Better plan on self-paying then, which I stinks but sometimes it not worth fighting as you won't win! Trust me I love to fight BCBS, and in all cases so far I have won, but not with clear written exclusions in the picture.
   — zoedogcbr