Question:
Please help me decipher this HMO exclusion

I have Blue Cross California Care,an HMO.The exclusion reads:"Obesity--Services primarily for weight reduction or treatment of obesity. This exclusion will not apply to treatment of morbid obesity as determined by BC HMO or the member's medical group if the medical group authorizes the treatment in advance as medically necessary & appropriate." Without the words "surgical treatment", does this mean wls is not covered? My BMI is 45 & I have some co-morbids. The word "treatment" is quite broad. Any interpretations would be helpful. Thank you;)    — [Anonymous] (posted on February 23, 2002)

February 22, 2002
Hi... I think you are probably OK! The key words are: This exclusion will not apply to treatment of morbid obesity as determined by BC HMO or the member's medical group if the medical group authorizes the treatment in advance as medically necessary & appropriate. NIH standards (National Inst. of Health) give a BMI of about 39 with comorbidities. When paperwork goes in make sure your Dr. sends medical history, letter of medical necessity and info on all of your comorbidities. I think so far it looks good for you! Obesity is overweight; Morbid obesity is more than 100# overweight with underlying health problems. Good luck to you.
   — AJC750

February 22, 2002
Best bet is to call the ins. people!!
   — Heather H.

February 22, 2002
sounds like it would be a covered service to me. It doesn't sound like it excludes surgical treatment for morbid obesity. Good luck.
   — Dawn H.

February 23, 2002
I think you're fine. I definitely read it that they will cover the surgery for morbid obesity. My insurance policy has similar wording, but they do pay for the surgery.
   — garw

March 1, 2002
I'm an insurance agent and my interpretation of this is that if your primary care giver or the person he referred you to says that you fit the criteria of morbid obesity and is define d as medically necessary. If you meet that criteria you should be fine. My best suggestion is to call ins. co. and talk to a rep. they should be help[ful in telling you what you need to do to get it approved. Contrary to many peoples thoughts the ins. co. are not out to get you. They pay for the benefits they provide. Many people tell you what their ins. covers, but they don't tell you what they pay for those benefits. Good Luck Dave!
   — David R.