Question:
Can I get approval?

I have BCBC of TX; Denial letter stated proposed procedure (RNY gastric bypass) is a contract exclusion. I am 48 years old, 5'2", 250#, have diabetes, hypertension, edema both legs, depression, stress, headaches, and increasing discomfort/pain back and legs. My primary MD recommended it and the surgeon agrees it is a necessity.    — Kay L. (posted on January 19, 2003)

January 19, 2003
Kay, I have been fighting this kind of exclusion in my BCBS of TN policy since last April. My employer even tried to get BCBS to change our policy to include this surgery, but they refused. They said that effective November 1, 2002, all contracts will have this exclusion. The only way around it is if your employer is self-insured, meaning that they pay the actual medical claims and BCBS manages the contract, providers, etc. If they are self-insured, they can override any denial if they want to. Unfortunately, I am covered by two insurance policies, both have exclusions, and neither my employer nor my husband's is self-insured. The advice I have given others in this situation is to continue appealing, and write letters to your state's congressmen and senators, as well as your state's insurance commissioner. This is the only way we will ever get insurance to pay for this life-saving surgery. Good luck to you. Ginger
   — Ginger N.

January 19, 2003
This could be a possibility of hair splitting. If in your approval letter your surgeon indicated he/she was going to do a 150cm bypass that could very well be why it was denied, but they won't come out and say it. My approval letter from BC/BS of WI indicated that they will not cover a mini or long-limb RNY. The definition for the procedure code listed says 100cm or less. Check your letter. If it says anything over 100cm then have it rewritten and resubmit. If there was no mention of of length of bypass then it might be a bigger battle.<p>I was just approved on Jan 3rd, 2003 but my policy is actually self-insured, but I know other people who have gotten approval on other BC/BS policies that were not self insured. I hope this info can help somehow.
   — zoedogcbr

January 19, 2003
Have your physician, surgeon, and a psychologist write up an appeal and you as well. That may help. Keep appealing until they give in!
   — Tracydarlin