blue cross blue shield

[Lap_dancer 8]

Hey Candle - if your EMPLOYER has an exclusion it is the EMPLOYER you have to appeal, to. The insurance company can only cover what their contract with the employer says they can cover.

Sorry, I am sure that isn't news you want to hear - but check with your HR dept to be sure that your company REALLY has that exclusion. When I was doing my insurance thing - I got a different answer from everybody I talked to when I asked that question. Your HR dept will be able to tell you FOR SURE whether the company has an exclusion. I wouldn't trust the answer from BCBS without a double check. Go to HR first, then confirm with Blue Cross. If HR and Blue Cross conflict in their answers - then get them talking on your behalf.

Good luck!

Thanks for this post.

I just finished with my second Appeal, next is state level. I will go through that unless I find success with my employer.

I read my contract and there is an exclusion to gastric surgery. It's very clear. But my doctor does support me in doing so and has written letters and provided clinical information. My insurance company told me that my employer could purchase the rider that included the surgery. I thought he was just trying to sell more insurance. So I called employee benefits and sure enough, the supervisor said "we get requests like this all the time for things like infertility...". I'm now going full on with my employer. I pay for insurance to cover me medically.

I will let you know what I find out tomorrow.

Best of luck.

[TracyinKS 7]

Lap Dancer: KEEP UP THE GOOD FIGHT! I will cross my fingers for the state reveiw!

[Candle 11]

Thanks Lap Dancer!

I am going to check with my employer today as well. I am lucky in one respect - I know my employer will try and help me as much as possible - I'm not just a faceless employee in mass of many. We are a very small company, I'm sure they just picked one of the cheaper plans to at least be sure we all have insurance coverage.

Hell - I'd even be willing to pay for the rider and/or change in my policy to be covered. It can't be more than the $25,000 the surgery costs!

I'm wondering about the appeal process though. Once you are turned down by the insurance company and then appeal with your employer, is this how people end up getting approved ---> the employer gives in and purchases the rider?

(again - I have BCBS as well)

[Lap_dancer 8]

Lap Dancer: KEEP UP THE GOOD FIGHT! I will cross my fingers for the state reveiw!

Thanks Tracy!!

..........................................................................

Anyone have an idea what policies generally stand for "medically necessary"????

[TracyinKS 7]

LD: I think that the medically necessary means all the bmi and comorbidity mumbo jumbo that bcbs puts out in their policy.

[Lap_dancer 8]

LD: I think that the medically necessary means all the bmi and comorbidity mumbo jumbo that bcbs puts out in their policy.

What does not compute for me is that I met the requirements set by BCBS corporate but BCBS of FL and my policy specifically denies coverage of gastric surgery. The clause that denies coverage is one simple sentence on my plan, "...not a covered benefit...". Other BCBS plans do cover this.

The BCBS plan that does cover gastric surgery requires it be medically necessary. This seems like a contradiction in terms. (to have the surgery you must meet the criteria of it being medically necessary. Now that you met the criteria of it being medically necessary, it doesn't matter because we aren't going to cover it anyway) This isn't computing to me.

At what point does my doctor's words "medically necessary" mean something??? He even wrote a very lengthy letter to my insurance.

This isn't making sense to me.

[TracyinKS 7]

That is why you need to appeal to the state.. it is your employers choice not to cover, and since you already appealed to THEM you need to take it to an outside agency........ so what about other insurance (spouse) have you checked into that route?

Oh and I think one of the moderators Andrea posted something that could make a difference on your SPD question.... she said if your insurance is self insured (by your employer) you have a right to your SPD. (mine is, which is why we hand them out at open enrollment)

Oh and another thing while I'm on this topic.... I called around for a psyc eval today and the place the really ticked me off.. was spouting off saying that they knew a bunch of tests would be required of me because they had two other patients from our company wanting to do the same thing and insurance was requiring a bunch of tests........ hmmmmmmmm.. this COULD be the difference between our PPO and CDHP.. but you see.. the SAME policy, same provider, same plan gets very different answers by bcbs.... (I'm using my flex dollars to pay for both my evals and I'm going to be ticked off if they come back on me) but like I've said before.. give me the dang band and I'll worry about getting them to pay for it later! LOL

(ok coming down off my soap box)

[Lap_dancer 8]

That is why you need to appeal to the state.. it is your employers choice not to cover, and since you already appealed to THEM you need to take it to an outside agency........ so what about other insurance (spouse) have you checked into that route?

Oh and I think one of the moderators Andrea posted something that could make a difference on your SPD question.... she said if your insurance is self insured (by your employer) you have a right to your SPD. (mine is, which is why we hand them out at open enrollment)

Oh and another thing while I'm on this topic.... I called around for a psyc eval today and the place the really ticked me off.. was spouting off saying that they knew a bunch of tests would be required of me because they had two other patients from our company wanting to do the same thing and insurance was requiring a bunch of tests........ hmmmmmmmm.. this COULD be the difference between our PPO and CDHP.. but you see.. the SAME policy, same provider, same plan gets very different answers by bcbs.... (I'm using my flex dollars to pay for both my evals and I'm going to be ticked off if they come back on me) but like I've said before.. give me the dang band and I'll worry about getting them to pay for it later! LOL

(ok coming down off my soap box)

What is CDHP?

I missed something, explain what you mean:

...but you see.. the SAME policy, same provider, same plan gets very different answers by bcbs....

Thanks Tracy.

[kwhenrykerr 0]

My girl had BC/BS and they were a pain in the back side. But we did not give up untill they paid $68,000.00 for her WLS plus the after care. Do not give up.

[TracyinKS 7]

LD: Our company offers 3 plans under BCBS: PPO-Plus, PPO-Base, and the CDHP (Consumer Driven Health Plan) otherwise known as an HRA (Health Reimbursement Account.) In the shortest explaination possible

PPO-Plus: Higher out of check, but cheaper if you use it... Lower deductibles and copays

PPO-Base: Cheaper out of check, more if you use it.... Higher deductibles, and copays

CDHP: Money is credited to your account (my case it is $1125) When I go to the doctor/pharmacy the full visit price comes out of that first 1125.. I have no Upfront deductibles or copays... but when I use the first $1125, then I get to the bridge (fancy word for deductible) I pay the next $1125, then once that is satisfied I go to 90% coverage level....

The upside is: if this would of been last year I spent a total of $600 on health care, and had we offered this plan I would of had the left over money added to this years begining pot......... oh and the premiums are $75 a month cheaper than the PPO-Plus plan, and it is SUPPOSED to give you more say over your health care choices.. (which is why they tout NO precerts or copays)

The CDHP is perfect for those who use very little health care or those who USE ALOT!!!!!!!!!!!

[cyndilou29 0]

I have highmark BCBS NJ and they are the worst for working with people. I was told by the attorney that I tried to hire that I would never beat them. I fought them on my own and finallly won by getting my husbands Union involved. Each company has it's own rules and then each policy can and will be different. It depends on what the employer wants covered. Each policy is custom made for each company. ~Mandy

We just switched to Highmark January 1. Do you know if it is the employer who makes the final decision on what gets covered if you are on a self funded plan? ie does the appeal go to them ultimately?

[Candle 11]

This is my first post here:

I have a policy with BCBS. It was an HMO plan w/ Anthem in CT, that was recently switched to a PPO plan so that I have coverage in the state I now live in, NY. I haven't even found a regular doctor here in NY yet actually.

They told me that they won't cover the band because my employer doesn't cover it.

Just to be clear - should I submit paperwork to them anyway and then try to appeal after I'm denied? Have people won on an appeal in a case like this? Or do they (people that have won after appeal) mean they were turned down and then won the appeal because their plan actually covered the procedure and as an individual, the request was turned down?

Does that make sense? hehe

To appeal, does that require an attorney?

Follow up on my own BCBS battle:

Turns out the exclusion is not my employer's doing but actually BCBS. We have a small business policy which is classified as "commercial".

WLS is not covered with a commercial policy.

I've been looking for another insurance plan that would cover it and really had no luck. Unless I want to pay upwards of $1,000 per month. I'd rather self-pay and not jump threw all their hoopes.

Unfortunately, self-pay of not an option for me right now. I'm going to submit a formal request to BCBS and try to fight it. Most questions about fighting exclusions seem to go unanswered, I assume that's not a good sign. I even contacted 2 lawyers and neither have been very good about getting back to me or even answering any of my questions.

[Mita 2]

I have BCBS of Neb ~ they covered it when I had the band put in but will not cover or maintain it now. They suck

[piercedqt78 658]

We just switched to Highmark January 1. Do you know if it is the employer who makes the final decision on what gets covered if you are on a self funded plan? ie does the appeal go to them ultimately?

I know they have changed the policy in the last 18 months. (that's when I was banded) I know that they claimed they never covered it back then. Now it may be up to the individual policy. ~Mandy

[Lap_dancer 8]

Here is what I found out on BCBSFLorida.

My WLS is an exclusion and that is why my claim is denied. I took it to a level two appeals within BCBS and it too was an adverse finding for me for the same reason. The language in my contract specifically states that WLS is not a covered benefit...not only that, no meds, no memberships, no medication..NOTHING...NADA ...to lose weight. That is pathetic.

*I believe adversities have seeds of personal growth in them. I look for those seeds during duress. I have found a field in BCBS's policy towards obesity healthcare. Yes, I will contact the newspaper. Yes, I will contact this person "Abramson" if I have the name right, forgive me if I don't but will be certain I do when I mail off my letter to him. BCBS is reviewing its weight loss provision in April of this year. I ENCOURAGE ALL WHO HAVE BCBS TO WRITE LETTERS.

Meanwhile: January 31st I have a meeting with the School Board Insurance Committee. They have the opportunity to purchase a rider for my surgery. I am appealing to them as a last recourse. I have requested my file from BCBS that they used in my determination, there will be a team of folks there and I intend to not just educate them but EDUCATE THEM.

If they don't approve the rider, they will atleast walk away with a knowledge of life as a morbidly obese human.

Plan B, going to Mexico. Nothing will stop me from getting this surgery.

I feel like I'm fighting for my life and this surgery is my Lorenzo's Oil.