I already had my sleeve surgery. I got a "preauthorization" from my insurance (Blue cross/blue shield of TX) for medical necessity (over BMI 40). I just got all the EOBs and every single one of them was denied. When I called the insurance they said that the "insurance" may have approved it, the "plan" didn't as they don't cover Bariatric surgery. He said I should appeal but because employer has that clause it's going to be a tough fight.

Any information you can provide on what to include (or exclude) in the appeal would be great.

I've not gotten a response from the doctors office (except surprise), so I think a peer to peer review is out.

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I appealed with statements from my other doctors making it a medical necessity. If you have other conditions get a letter of medical necessity from each one, cardiologist, General dr, endocrinologist, orthopedic..... My appeal was won fairly quickly.

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@@pb88 - Have you had any luck sorting out your insurance issue? I also have BCBS TX and your post makes me nervous!

It has been resubmitted by the doctors office and I should know next week if it gets approved or if I have to appeal. Doctor's office said they have never had this situation before.

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@@pb88 - Sending good thoughts and prayers your way. Can I ask - which doctor did you use?

Edited September 21, 20169 yr by JMill 72

I had BCBS & I went through the same thing & I learned that it also has something to do with company you work for if its insurance through your job ... & I worked for a non/ profit organization ,Sometime that employer will have that claus in there where none of the plans will cover Bariatric surgery no matter which one u choose PPO,HMO it dnt matter & that's when i dropped ????mines ...

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It's not the insurance company, it's whether the company you work for opts to include bariatric surgery in it;s group policy. If your company does not, I don't know how your surgery would be covered, especially now. I certainly would turn this over to the surgeon's administrative staff though...they should have known this before they operated on you.

What was the purpose of the prior with then? That's to authorize the surgery based on your benefits! That's ridiculous!

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@@pb88 - I've been thinking of you and wondering if you had any luck with your insurance company. Did they end up paying your surgery bills?

See if you can get a case mgr at the insurance company to help fight for you.

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