Other CPT Codes/ Misquote

[kcollier84 0]

Well,

After EVERYTHING I went through, all the procedures, all the stress, it turns out BCBS misquoted my Provider and the treatment of obesity is an exclusion. BCBS told my provider that yes wls was covered, yes the sleeve was covered, and here are the things that need to be done before pre auth (endoscopy, dietitian appointments, upper GI, psyc eval...yada yada yada). :scared0:

I was about a month away from surgery when I was looking through our plan docs for chiropractic information. All of a sudden I was bit in the face with an obesity exclusion! What!!! OMG, I called my provider. She called BCBS and sure enough, excluded. BCBS said don't worry, if it s a misquote it will be covered....

I waited a month for a misquote review only to find out that their denial reason was "A misquote of benefits has been reviewed and denied as there are no claims on file for this provider." Well of COURSE there are no claims...you told my provider it was excluded in the second call! :cursing:

I am having my provider actually do a pre-auth so that I can get a denial letter. Hopefully I can appeal somehow. :001_tt2:

During all of my testing, I found out I have a moderate hiatal hyenia, high blood pressure, and acid reflux. Has anyone had any luck getting approved using these diagnosis codes? My insurance has an exclusion for any treatment of obesity but not the surgery itself (hence the misquote I think.):confused1:

Any help would be appreciated. I am also considering contacting the Insurance Commission regarding the misquote, what do you think?

[Stacy160 201]

Honestly, I think you're out of luck. If treatment for obesity is specifically excluded from your policy, then it's because your employer chose not to pay for that coverage, and not because the insurance company doesn't cover it. If bariatric surgery IS a covered benefit (and it doesn't sound like it is) but they just don't cover VSG, then you stand a chance on appeal. From the sounds of it though, it's not going to be covered. It'd be like paying for PL & PD insurance on a car, then asking the insurance to buy a new car if you crashed--if that makes any sense? Sucks, but it's your employer's decision to exclude obesity-related treatment, not the insurance's. I know...been there, done that, and it blows.

[kcollier84 0]

Thank you for the advice. I actually work in the benefit office and we didn't choose not to have WLS, it was just part of the insurance package. Specifically tailoring a plan is expensive for the company!

I am thinking about Mexico, but it seems as if that is going to be about $6,000. I think I may be SOL....

[mrspalmour 0]

Unfortunatly I work in UHC appeals and we get these alot. We have special verbiage we put into letters that states since the benefit misquote did not result in any financial burden we dont consider the misquote as grounds to covere somthing. There is alwasy that sweet little disclaimer given in the calls about this is not a guarentee of benefits they are considered based on plan provisions when the claim is reviewed. bla bla bla. We do however put an apology in there for you. I know no help at all. I hope some day there is a way that all ins companies can get their ducks in a row and be able to provide members and providers with the correct information from the get go. The insurance companies are trying to make the member responsible for understanding their benefits. I work in it and still dont understand it all lol. Sorry to hear about your story. I hope somthing works out for you.