Lap Band is an Exclusion

[sweetrepose 1]

Hi there! Received my denial from Regence BlueCross BlueShield of Oregon today. Lap band is exluded in which I new! I am trying to fight it. This is a portion of the letter they wrote...

We have reviewed your concerns and the information that you provided. Under your gruop contract, through (my employer), the treatment for obesity is specifically excluded from benefit payment, regardless of other medical condtions that may be related to or caused by obesity.

When a service, treatment or supply is not covered, under the contract, the member.patient is financially responsible for the non-covered service. Our denial of benefits is not based on the medical appropiateness of the requested surgery; it is based on the specific limitations of your contract. You may wish to pursue alternate means of financing for this procedure.

I regret that our findings could not be more positive. Let me advise you that, on a disputed determination, you are entitled to three levels of review. This grievence is the first level. You have the right to file an appeal with Regence BlueCross Blue Shield of Oregon. In case you wish to exercise your right to appeal. I have included a form for your use. Your appeal must be submitted within 180 days of this determination.

In the case of an adverse benefit determination you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevent to your claim for benefits. Additionally, you have the right to file a complaints or seek assistance with the Oregon Insurance Division by calling (503)947-7984 or writing to Oregon Insurance Division Consumer Protection Unit

350 Winter Street NE, Room 440-2 Salem, OR 97310 http//www.cbs.state.or.us/external/ins

Sheri Yuckert

Grievance Coordinater

Sooooooooooooo. What do you all think???? Do you think I am wasting my time trying to appeal it because it is excluded???

HELP! The doctors office charges $19,500 for Lap Band here in Portland Oregon. OUCH!

Kathy

[Alexandra 55]

Kathy, exclusions are the very hardest things to fight. The carrier isn't doing anything wrong, they are delivering exactly the service the contractholder (probably your employer) is paying them for. They have absolutely no responsibility to go one step farther than that, and no one is going to hold them resposible. There's no point in appealing such an exclusion to the carrier or the department.

Your best (and possibly only) bet is to appeal to your employer. If there is any wiggle room or any way an exception can be made, they are the party who must request that it be made. Call your HR department and see if there is anything they can advise.

Good luck!