Denied- maybe I went about it wrong?

mstockett · June 14, 2005

I simply called my insuarance company (BCBS of Alabama) and asked if the lap band was covered under my policy and the response I got was no. I didn't ask why or anything else as my heart dropped into my stomach and I didn't know what else to say but "ok". Could she have taken the question in terms of it being an elective thing? In other words, if my Dr. submitted it them stating health reasons, might I then be approved? I have not spoken to my Dr. about this surgery yet, I figured checking with the insurance company first was the best way to start, but maybe not.

I did read on the banstersinsurance yahoo group in the database that BCBS of Alabama covered this surgery 100%.. was this just one persons experience? I am not sure what that list is really saying. I know that when I was considering gastric bypass last year I read in the Insurance coverage that 1 weight loss surgery would be covered and do not recall reading any exceptions to that. I will need to go back and dig that book out again.

Do you think I would have a better chance get apporved through my Dr? Or is no basically NO and I would have to go through an appeal? Medically I think I am a candidate for this surgery. My BMI is 51, high blood pressure, father had heart attack at 50, his father died of heart attack at 60, 2 uncles on my moms side have had heart attacks and her parents have both had numerious heart bypasses. My mom, grandmother and uncle also have diabetes.

Any insight on this would be great. Thanks

ETA: I see in my policy under exclusions that it does not cover services for obesity. BUT in the same paragraph is goes on to say, "This exclusion does not apply to surgery for morbid obesity if medically necessary and in compliance with guidelines of the Claims Administrator." So maybe I answered my own question. I am just not sure who/what the Claims Administrator is and what the guidelines are.

Alexandra · June 14, 2005

You weren't denied, you just got a flip answer from some customer service rep who probably didn't know what you were talking about.

You have read the fine print. If your doctor believes you to be medically qualified for bariatric surgery (ANY kind of weight-loss surgery has the same medical qualification guidelines), then you should have your doctor go about the process of submitting a request for precertification. No one can answer you definitively until YOUR medical case is made--unless there is an exclusion on your policy, which you already know there is not.

You might try calling again and asking if you can be sent a copy of the medical criteria for bariatric surgery. Don't ask if it's covered, just what they are.

mstockett · June 15, 2005

Thank you Alex. Here I am just starting out and I thought it was going to end before it even started. I will continue on as I had planned and see my Dr. and go from there as well as call BCBS back and get them to send me their criteria for the surgery. Thanks for the advice and confidence.

Melissia

Heather Joy · June 27, 2005

Hello! Hey,I called my insurance to see if i had gotten approved for my surgery (after Dr submitted everything),and the lady said "yup,you were approved!) and i was SOOOO excited!!A couple days later my doctors office called me and said i was denied . I called my ins co and complained and they cojnfirmed i had indeed been denied and that the lady just "must have been looking at the wrong screen"....But i eventually got approved because i wrote them a letter and sent a bunch of other proof i needed this surgery.

So,in closing dont always take their word for it,sometimes THEY dont even know what theyre talking about!LOL

I wish you the best on your weight loss journey and let us know what happens!

mousecrazy · June 28, 2005

Hi, The surgeon's asst. asked me to call my insurance and ask what the criteria for lap band was, and when I did, they said they don't have "set criteria" but the dr. would have to submit a benefits request...so I called the asst. back and told her that. Then, I took the big, long, questionnaire thingie up to the surgeon's office so she could call my insurance co. herself. She told me they neededletters of med. necessity, and a certain # of lbs to lose, or a BMI over a certain amount. I qualifed under those terms. Still, though, the surgeon has to actually submit the letters, and the request,etc. and then the asst. said we'd play the waiting game. Whatever that means. I hope some of this info helps you. Don't stop. I hate the term morbidly obese, but you gotta love it if it qualifies you! Cindy