I ran into an issue today with my Highmark Flex Blue PPO 1000 insurance. The first rep I spoke to in Feb, said that I would have to cover 20% of the sleeve surgery, but today the rep said I wasn't covered at all for anything and there were no notes about the previous rep I spoke to.

Because of my income I can get on Medicaid in Pennsylvania. I have been paying for insurance out of pocket, because I like my family doctor and I didn't want to have to go to a clinic. However, the surgeon's office said that it will be covered 80% and there maybe other things like the hospital that won't be covered.

Has anyone in PA used medicaid for a sleeve?

Does anyone think that I should spend more to get a new policy from Highmark which does cover surgery?

Any other suggestions/help?

Thank you!

I would call Highmark back, ask for a copy of your Policy and ask what page and item the weight loss exclusion is on. Since you have gotten conflicting information make them document the actual exclusion in the Policy.

If you qualify for Medicaid I am surprised it wouldn't pay at 100%. I am not as familiar with PA Medicaid but any other state I have seen has 100% coverage for any covered service. I have never seen one that has co-insurance, co-pays or deductibles. I pay medical claims for a living so deal with many policies and many states.

Thank you NikkiDoc.

I did look at my hard copy of the plan and bariatric surgery was listed under excluded services. However, I'm going through all the available plans for Highmark and so far all of them have bariatric surgery under the excluded list. I was under the initial impression that it would be covered depending on how the dr coded the procedure.

Can I call Highmark and ask them if they have any plans that cover this? Or would that make changing a plan impossible? This is the main thing I am unsure about.

I am going to call about Medicaid this afternoon. The only thing that worries me is that I was told it will take up to 30 days for them to process my application. Also that I loose the options I have now with the insurance I pay for myself. Such as seeing my primary care physician.

My surgeon's office confirmed that all 15 individual plans offered by Highmark in PA do not cover bariatic surgery. I really wish someone would have clarified that this is the case with most individual plans, and for coverage you need to essentially have insurance through an employer.

I'm going to have to apply for Medicaid in light of this new info. Hopefully it will process quickly and won't affect the 5 months of classes and appointments I've already had.

I had BCBS PPO when I started the process. They covered the sleeve. I ended up switching to a UPMC plan because of my job. I would definitely look into this more. Ask your doctor for the exact billing code and give that to the insurance.

If WLS on the exclusion list then unless the doctor fraudulently codes it I don't see how it would get covered. The computer would be coded to either automatically deny certain CPT codes (procedure codes) or flag them for review by an examiner.

There would be certain supplies and procedures that are not normally covered but if you have a certain diagnosis would be covered. Example birth control pills for contraception are not covered but would be covered for heavy menstration, PCOS or endometriosis. (Obviously this is a pre-Obamacare example)

If you had a hiatal hernia repair and sleeve done at the same time then the hernia repair would likely be covered. The sleeve portion would likely be denied. The anesthesia and hospital fees would then likely be pro-rated and anything directly related to the sleeve denied. Therefore the swallow test the day after may be denied as you would not normally have that with a hernia repair.