Question:
Has anyone been told surgery was a covered benefit and then denied and told it wasn't

I called my insurance company with the CPT code 43846 to see if Gastric Bypass was covered Back in May when my doctors office suggested I do so. I was told YES, it would be covered If deemed medically necessary. Today, my doctors office called and told me I was denied because I have a small group policy. I called my insurance, they said If I had gone ahead and got the surgery when I was told it was covered then they would have to pay, but now that they told me it wasn't it's to late. I can't believe that! What should I do now?    — Loretta W. (posted on July 23, 2003)

July 23, 2003
Loretta I had the same problem with CareFirst BC/BS - Exactly. I made my surgeons appt (after first calling and making sure they covered) then was denied due to an exclusion. The problem was with the contract between my husband's employer & Blue Cross. What I had to do was appeal to the employer thru a union representative. It was really long, messy & extremely stressful. I never did get my appeal denied they just kept saying they needed more information & more time to make decisions, etc. That lasted from 11/02-6/03. I was able to obtain different insurance thru my job & relieved to tell you I finally have a date! October 23, 2003! If you want more details - feel free to email me [email protected]
   — j A.

July 23, 2003
Hi. I do all of the approvals for my doctor...we are in DC so I deal with BCBS of MD all the time. i knwo that the small employer group ins does not pay for WLS. I believe that even if you had of sought approval a few months ago, you would have been denied. You can try again to check your benefits by calling the customer service number on your card. The nurse, Terry, that does the medical review for your ins is usually correct. If you want to email me you can at [email protected] Luck
   — Mandybub

July 23, 2003
The exact same thing happened to me with BCBS PPO.BCBS covered the surgery if medically necessary BUT it was not a covered expense by my employer.
   — Lisa F.

July 24, 2003
Yep, that happened to me in 95. I had an approval by word and then they called and said my policy had an exclusion. The insurance company has many policies and some are cheaper policies and have those exclusions that your employer chooses to save money. If it would have been in a letter however, they would have had to pay.
   — ZZ S.