Highmark Bcbs Denial

[tumblersmom 60]

I'm new to this sight but was wondering if anyone out there has been denied by Highmark BCBS & won their appeal. I have a bmi of 42 & have been denied because I'm under a bmi of 50. I know that the sleeve is the best option for me but am wondering if there's even a chance of having it overturned. They will cover lap band or bypass for me but am not comfortable with those options. When I first looked into surgery I thought lap band was the way to go but upon doing more research the sleeve is definatly the best option for me. So if anyone has any advice or tips for me please help!!

[Vance_ 217]

Hmmmm....I have Texas BCBS and I had a BMI of 42 and was approved fairly quick. I would definately appeal this. It's odd they would deny you for the sleeve but approve bypass. Good luck to you!

[IowaAndy 95]

Each BCBS plan has different exclusion in their policies. You would have to dig deeper into what you plan will cover and what it will not. My BCBS in Iowa would not cover the sleeve so it made no sense to appeal their decision. They would pay for the band and a bypass but no sleeve.

[Tif 2.0 141]

Sometimes its not even the insurance company per se, but the contract with the employer. Your employer is the one that puts in the inclusions and exclusions and the insurance company provides service around those parameters.

Do you have any comorbidities, like diabetes, sleep apnea, high blood pressure? You might have better luck with an appeal if you do.

[tumblersmom 60]

Sometimes its not even the insurance company per se' date=' but the contract with the employer. Your employer is the one that puts in the inclusions and exclusions and the insurance company provides service around those parameters.

Do you have any comorbidities, like diabetes, sleep apnea, high blood pressure? You might have better luck with an appeal if you do.[/quote']

Yes I do have co-morbidities.

[tumblersmom 60]

Hmmmm....I have Texas BCBS and I had a BMI of 42 and was approved fairly quick. I would definately appeal this. It's odd they would deny you for the sleeve but approve bypass. Good luck to you!

Thank you!! I thought it was odd myself since the bypass is a more complicated & more expensive surgery.

[IowaAndy 95]

I agree that is it many time the specific contract that is worked out between your specific employeer and the insurance carrier. As for me I had hypertension, sleep apnea, and borderline diabetes. My insurance initially paid for the lapband but when I wanted to have the sleeve as I still had around 100 pounds to lose they would not cover the removal and the sleeve. I was told that they only were approving the lapband and the bypass. I think that this was an agreement between them. The sleeve has not been one of the most used in recent years and many either had the lapband or the bypass. I think that as time goes on that this will change and they will add the sleeve but it all takes time. It is just like some companies do not cover any type of infertility treatment in their policies either but now some are adding them. These procedures all cost money and it too many people are using this feature it becomes more expensive for all.

[UPRR Wifey 89]

There is a lady that calls herself Texas89 on here, she had highmark and her BMI was not 50, she said she won her appeal you should try and contact her. I also have Highmark, my BMI is over 50. I am waiting to hear back from them. How long did it take you to get a response? Good luck