insurance said Lap covered... now said it's not?

Carrin · July 14, 2006

I called my insurance company Highmark BCBS on june 30, 2006.

I followed these directions from bariatric center to a tee:

" Your first question to yourinsurance company should be, "do I have a policy exclusion for weight loss surgery?" You do not want to hear that you have an exclusion. If you do not have a policyexclusion, then ask if you have coverage for the weight loss surgery procedure thatyou desire, either the Laparoscopic gastric banding (lap-band) with a CPT code of 43770 or the Laparoscopic Roux-en-Y gastric bypass with a CPT code of 43644."

I was so excited to hear... YES an exclusion for obesity... but NO exclusion on MORBID obesity. He went on to explain their definition of morbid... bmi 35 with comorbidities and bmi of 40 without. He explained the dr. supervised diet also. I was on the phone with this guy for what seemed like 30 minutes. He explained ALL the coverage... the lap surgery was covered 90% after my deduct... etc. .... etc.... etc.... he even gave me provider information in that phone call.

I have since gotten the ball rolling. I attended a seminar today and when I got home I noticed that I didn't write down the supervised diet information when I talked to them... I want to have all my ducks in a row so I call them and they tell me I have no coverage for the procedure....????!!!!!

I am so upset I began crying on the phone... great huh.... I don't understand. I told the girl I didn't know who to believe the guy who gave me VERY specific information or her...? She spoke to her supervisor several times during the call and verified that I did call when I said I did-- and that the first guy gave me info on general laproscopic surgery. WHY then did he give me bmi information etc. I am pretty sure that he even referenced a specific procedure #.

This totally sounds like a conspiracy! The supervisor is going to pull the tape and hear what actually happened.

What will happen then? anyone know? This is a great big load of flaming donkey doo! They apologized and will repremand the guy who made the error (I didn't want that-- I just want them to do the right thing and cover the surgery)

according to the woman I should recieve a call back monday. Any thoughts... sorry so long. Carrin

FunnyDuddies · July 14, 2006

in my opinion, if they have a tape of the guy telling you it is covered, and you have already started the process to get the band, then you should have someone from obesity law make your case for them and shove it down their throats. how awful!! I hate when ins screw around with us on this.

Tricia K. · July 14, 2006

This is a quote directly from Sandy R's response to someone asking a similar question on obesityhelp.com:

"You may also wish to contact an excellent banded attorney, Steve Kalman, for help. He has obtained reversals of denials in many cases, (with just a letter or two on your behalf) when an ins. company pays for bypass or VBG, but refuses to pay for banding. Not allowed! They CANNOT require you to have a more dangerous and less effective procedure, when a better and safer one is available, and for far less money! Steve's website: www.BandedLawyer.com"