Question:
What is going on with BCBS?
It says in my book they approve for WLS. And now all I hear is that they are denying everyone! What will I do? Does anyone know if this is a fact? I have BCBS PPO — Sabrina H_NC (posted on August 27, 2002)
August 27, 2002
I have BCBS of VA and was just approved a little over a week ago. I've been
hearing things on the message board and I myself am a little worried. I
would call BCBS if I were you to make sure they still cover the surgery. I
can't see why they would change their minds. Good luck to you!
— Heather B.
August 27, 2002
Mine says its a covered procedure but they are denying me to the end I
have bcbs fl ppo read my profile for more
walter and kelley are helping me but they say they have never dealt with
anything like this
— Linda L.
August 27, 2002
Hi, I have BCBS PPO and was approved with a BMI of 40 and no comorbs about
3 1/2 wks ago. Maybe it varies by employer or state. Good luck.
— TP
August 27, 2002
I started seeking insurance approval for my wls surgery back in April of
2001 with Anthem BC/BS PPO (Blue Access Plan). Everytime I sent them
something, they would ask me for more information. They had me see a
dietician, a pstchologist, and a surgeon, and then said I did not have
enough weight loss history documentation. So in January I started over,
going to the doctor every month, being weighed every month. By the end of
June I was sick of it. I pulled out the papers I had from the Lindstrom's
law office and I called Anthem. I told them I wanted to start the appeals
process and I had retained an attorney (little white lie - I had every
intention of doing it, but I had not actually sent the money yet). I was
told I would have to go through the grievance process first, which is
basically what they call the first level of their appeals process. My
denial was overturned by Friday of that week. That Monday I went to my
surgeon's office and they said they had a surgery opening the following
Monday (07-08-02). I took it - I was afraid Anthem might change thier
minds! Everything went just fine during my hospital stay, and I got my
approval confirmation from Anthem both by fax and through the mail. Now, 7
weeks after surgery, my bills are coming to me unpaid. It seems that the
appeals dept. at Anthem never forwarded the information that my denial was
overturned. So now they are saying they will pay for the surgery, but first
they have to figure out a way to override their system so they can rerun
the claims. Honestly, dealing with Anthem has been the worst part of this
entire experience for me!
— Jenny S.
August 27, 2002
I have BCBS Federal PPO (Horizon in NJ) and I was given an
authorization/approval code over the phone. I think that each
state is different.
— Michell C.
August 28, 2002
My BC/BS policy approved in 9 days, having surgery 9/25/2002
By the way the determination is made by the particular bcbs
policy YOUR own individual employer has negotiated . All bcbs policies
whether
hmo, ppo, etc are not created equal.
— **willow**
August 28, 2002
Oh my goodness...I'm right here with you...Blue Cross Blue Shield of Texas
(self-funded) for state employees through ERS (employee retirement system),
and the exclusion basically says "Weight reduction programs, services,
or supplies, even if the participant has medical conditions that might be
helped by weight loss; or even if prescribed by a physician". They've
stuck by their exclusion adamantly, but I called BCBSTX to complain because
I heard someone got the surgery approved. They transferred me to their
Complaints Mgr, and I was told by her that this surgery would be covered if
a doctor wrote a pre-determination letter based on medical necessity. I'm
now working w/CompassWLS.com to get this approved. My new insurance policy
is effective 9/1/02, and I have to wait until then, but there's atleast a
little bit of hope that they can't just deny this surgery anymore. In
Texas, there was a recent victory for patients' right w/regard to
"medical necessity" against an HMO for denying coverage for a
treatment that resulted in his death...the reward, $40 million to his
family, that was meant to be an eye-opener for the insurance companies who
are essentially practicing medicine by denying treatment. An article about
this trial can be found on insure.com. I'm planning on sending them half a
forest's worth of documentation, including docs from NIH re: the effective
treatment for MO being WLS. If they say in the book that they approve,
gather your information, meet with your doctor and send in your request or
start working w/a bariatric surgeon in your area...don't just jump on the
rumor bandwagon...find out for yourself!! :)
— Lynda L.
August 28, 2002
I have BCBS of GA PPO, I have a written exclusion policy that excludes any
care or surgery that relates to obesity. I called the insurance company
and was told that I do have an exclusion policy but if I could prove it
medically necessary I could get approved for the surgery. I'm waiting now
for my appointmnet with my surgeon in October. Don't give up I've seen
where a lot of people are approved. Good luck!
— Kimmie C.
August 28, 2002
I have BCBS PPO of Pa. Not all policies all the same. Mine had an
exclution. It stated that thay didn't cover surgery for weight loss except
for mobidly obese (which I am) My first letter was denied due to lack of
information and also that it was sent to the wrong address the first time.
So make sure that it goes exactly where is has to. Check you book and see
where to mail pre-certification. The second time i made sure it got to the
correct address with plenty of medical information and I was approved then.
Make sure you have lots of medical info to back up why you need the
surgery. Sometimes weight alone doesn't get you approved. I wouldn't panic
though if your policy says it covers it. Good luck
— Lori M.
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