Ins Policy Ok's Procedure Code But Not Diagnosis Code?

[flore008 0]

Help! Doctor office called insurance and received pre-approval twice from 2 different reps. Went on and did all the required tests needed by ins company. All info then submitted to insurance co and i was then DENIED!!! Doctor office said that i was denied because ins co said my plan excluded bariatric coverage, but because ins co misquoted me i could get exception. Went to HR and they contacted BCBS who then investigated on thier end. Ins co claims they gave preapproval based on procedure code given b/c that code is not exclusion of policy but were not provided diagnosis code until the medical review was submitted. the diagnosis code was exclusion of policy.

Doctor office said they have to provide both when getting a pre-approval. They are not researching it more to see what went wrong.

Has anyone had this same problem? Why would ins plan cover procedure but not diagnosis? Doesnt make sense to me.

Your thoughts and experience on matter would be appreciated!!!

Getting discouraged!!

[cheryl2586 3,053]

Well my husbands plan is BC/BS and they don't cover anything to do with any weight loss surgeries. I don't know the doctors office put the wrong code in. They have their own other obesity related crap like they will give 10% off Jenny Craig or off a fitness club but wont pay for weight loss surgery. I would file an appeal on the basis that you were preapproved and then make your doctor resubmit with the correct codes. Thank God I had different insurance when I had mine done. They paid 100% at that time.