Question:
Has anyone with bc/bc with a exclusion ever appealed and won?

   — [Anonymous] (posted on December 16, 2001)

December 16, 2001
Hi, I have BC/BS of Louisiana. The policy has a written exclusion and I am trying to get my husbands employer to change there policy. It isnt really BC/BS fault, its just how ever the policy was bought it happened to be the one with this exclusion because normally BC/BS does pay for WLS. So it is really up to the employer. I am still working on my letter by the time I get done it will be 10 pages! If this doesnt work I am planning on purchasing an individual policy of my own through Ochsner, and there are no exclusions in there policy. Good Luck and feel free to email me with any questions.
   — lesleeloo

December 17, 2001
Hi, My husband's BC/BS policy had an exclusion and my first visit and surgery were initially denied. I wrote ONE letter and was then approved. E-mail me and I will send you a copy of the letter if you like. Good luck! Kathy
   — Kathleen M.

December 17, 2001
Kathy, I would love to see a copy of your letter you sent. It may help in my case. But I can't get to your profile. Please email me if you can. Thanks!
   — lesleeloo

December 18, 2001
Kathleen, I would love to have a copy of your letter if you would send it to me. I was unable to re access your profile but if you would mail it to me at [email protected] I would be so grateful. I am hearing so much about BCBS. I have BCBS of Texas. And although I am told that in general BCBS pays for this surgery. It seems to me that they can't find many policies that have it covered. I've already been told on the phone that I'm denied after I was told once it was covered. They seemed to have found the exclusion for WLS after I started the procedure. But, If you'll send me your appeal letter I would appreciate it.
   — gracie B.

December 29, 2001
Kathy, PLEASE e-mail me any information you have on getting approved through BC/BS of Texas. I have been trying to get approved through BC/BS also without any luck. Any assistance you can give would be GREATLY appreciated! [email protected] THANK YOU!
   — Laura C.

June 12, 2002
Gracie, Did your appeal letter for BC/BS-TX get you past the exclusion? If so...do you mind forwarding me a copy so I can see what you did? Thanks so much!!
   — Lynda L.

July 8, 2002
GOOD NEWS for BCBS of TEXAS insured folks: I've been working w/the group at COMPASS, used to be IMAGES, and they've confirmed that the exclusion isn't iron-clad...the medical necessity option has worked, and they're working with me to get approval based on that. I know there are several who've tried to get past this based on a LOMN and were denied, but my case-worker lady seems confident based on the information provided by her contact at BCBSTX. See below: Dear Lynda, I spoke with Lettie at Blue Cross today and was told that they will consider this surgery if medically necessary, however as you have an HMO they will not allow you to go out of network. I noticed that you stated that you will roll over to PPO in September. I would suggest we wait until after September 1 to submit the letter of medical necessity for approval as they will certainly deny it due to being out of network. Please let me know how you would like to proceed and thanks for letting us know that they will consider this procedure. Up to now we have always been told that this was a "definite exclusion" on this policy even with medical necessity. Thanks and I look forward to hearing from you. Sheridan at Compass GOOD LUCK EVERYONE!! :)
   — Lynda L.