Insurance Denial For Gastric Sleeve Surgery From Anthem Bcbs

[BrandNewMe11 1]

Hi, everyone. I'm completely brand new to the forum but have been reading the posts for months. Got the courage to see the surgeon after decades of weight loss struggle. My first appointment was in October, went to the seminar, saw the dietician, had the labs, EKG, EGD, sleep study and got all my medical records detailing my multiple attempts at weight loss in the past. This was all submitted to my insurance company on Nov. 22. My surgery was scheduled for Dec. 12th. But then the insurance decided to give me a big, fat, denial (no pun intended!). My husband and I pay for our own family plan. We do not have a workplace insurance. I thought Anthem was supposed to be so great and has offered great coverage in the past, but not this time. I called the finance officer at the hospital and the cost is $22500!! Now, I do have a wonderful husband who said he would pay for it as a Christmas/birthday gift (and also because I've been wanting this for so long). So I'm going to schedule the surgery for the last part of January 2012. But I feel so guilty spending this money. I feel this is why I pay for insurance. What upsets me the most, and sorry if this offends anyone, is that in the state of Kentucky the gastric sleeve procedure is a covered service under state Medicaid. And yet I pay thousands of dollars a year for Anthem and get denied. They say it is a "policy exclusion", but when I called them prior to my first doctor's appt. they said it only needed to be pre-certed. Oh, well, I guess this is one of life's lessons. Whether I pay for it out of pocket or not...the end result will be the same.....A BRAND NEW ME!!

[jasleeve 440]

i will keep u in my prayers!

[New in 2012 14]

You can appeal the decision. Be sure to document everything, including the call information that you made prior to the 1st dr. visit. It's a long shot, because policy exclusions are an industry standard to get out of coverage (they often are not listed in the fine print, in fact.) If you are still denied, I would recommend looking at the fine print of your policy, and if bariatric surgery is not a stated exclusion, I would write a letter to the state board of insurance to lodge a complaint. This kind of practice won't stop until/unless enough people protest it.

That being said, I encourage you to go ahead with the surgery. There is no better investment than in your health. It will be dollars well spent with a return you will reap for the rest of your life!

[BrandNewMe11 1]

Yes, spending $22500 is a lot of money out of pocket, but it is an investment in my health and future. A future with my husband and 7 year old daughter. Mexico is out of the question for me, I have no one to travel with me and/or help. The funny thing is...I gained 10 lbs. just to get into the qualification range. I am not a diabetic or have HTN...but the other co-morbidities qualitied me. Switching to another insurance in the state of Kentucky, when you pay for you own health insurance, leaves me with only one other option which is Humana. And this coverage is worse than Anthem's. The only reason I know this is that my husband and I are both specialty doctors (and no we are not hospital employees). We deal with insurances all the time!!! And no, being a doctor does not get you special privileges from the insurance company...as my ANTHEM denial clearly indicates. But when I get to the office tomorrow, I'm calling Anthem's pre-cert department (again) and let 'em have it!!

[cathyg 4]

I have Anthem BCBS through my employer and it was fully covered at the Cleveland Clinic/Florida

[Swimmer 199]

So sorry. I'm waiting on Anthem too. I've been very worried about a denial as well. How long did it take? I hope you can appeal.

[cathyg 4]

Maybe you can find another hospital--the one I went to is a Center of Excellence for Bariatric surgery--maybe there's one near you--it could make a difference--in the meantime, I'd appeal.

[hadouni 301]

I have BCBS PPO and I just found out I was approved and it took less than a week. I went out on a limb and called the insurance line and found out that way. I called my surgeon and they didn't even know yet but the info was there when they looked for it. I have to go to the place they choose and there is only one place near me. I think this is also specific to my employer's plan because there are other places near me that are considered "Centers of Excellence" for BCBS that I can't use with my plan. I finally went through my employer's benefit office to get some confirmations of coverage since I was getting the run around early on.

Good luck and don't give up!