Help me interpret this- BCBS of GA

[chanou 0]

Can someone tell me if that means that I won't covered for the laopband- I just went to my seminar yesterday?? Thanks

This what is under my covered benefits in my certificate booklet

Obesity

Covered Services for obesity include up to two nutritional

counseling visits when referred by your Primary Care

Physician. Prescription Drugs and any other services or

supplies for the treatment of obesity are not covered.

Surgical treatment of obesity is only covered for patients

meeting Medical Necessity criteria, as defined by us. Precertification

is required, and coverage is only provided for

gastric bypass or vertically banded gastroplasty.

and then under exclusions and what's not covered:

Any services or supplies for the treatment of obesity,

including but not limited to, weight reduction, medical

care or Prescription drugs, or dietary control (except

as related to covered nutritional counseling).

Nutritional supplements; services, supplies and/or

nutritional sustenance products (food) related to

enteral feeding except when it’s the sole means of

nutrition. food supplements. Services for Inpatient

treatment of bulimia, anorexia or other eating

disorders which consist primarily of behavior

modification, diet and weight monitoring and

education. Any services or supplies that involve

weight reduction as the main method of treatment,

including medical, psychiatric care or counseling.

Weight loss programs, nutritional supplements,

appetite suppressants, and supplies of a similar nature.

Procedures including but not limited to liposuction,

gastric balloons, jejunal bypasses, and wiring of the

jaw.

[Alexandra 55]

Surgical treatment of obesity is only covered for patients

meeting Medical Necessity criteria, as defined by us. Precertification

is required, and coverage is only provided for

gastric bypass or vertically banded gastroplasty

This is the key provision. Are you medically qualified for bariatric surgery? If you are, then your carrier does provide coverage.

The fact that only two kinds of surgery are mentioned specifically just means, to me, that it was written some time ago. Adjustable gastric banding is a newer version of vertical banded gastroplasty, which is pretty much not done any more. My guess is that the boilerplate language in this contract has just not been updated to keep up with medical developments.

Call your carrier and ask for their current coverage policies on bariatric surgery. But overall I'd say your contract is good news, because bariatric surgery isn't excluded. If they deny based on something other than your medical criteria you'd have an EXCELLENT case for appeal.

[chanou 0]

Yes I am medically qualified- My BMI is 46, I have PCOS and diabetes. I did called and a rep told me that baraitric surgery was an exclusion in my contract- Then i started doing my research and reread the the certificate and found that clause under the covered benefits.

I am concerned because under exclusions, it says that it excluded treament of obesity yet the above clause was in the covered benefits- It's like they are contradicting each other.

This is the key provision. Are you medically qualified for bariatric surgery? If you are, then your carrier does provide coverage.

The fact that only two kinds of surgery are mentioned specifically just means, to me, that it was written some time ago. Adjustable gastric banding is a newer version of vertical banded gastroplasty, which is pretty much not done any more. My guess is that the boilerplate language in this contract has just not been updated to keep up with medical developments.

Call your carrier and ask for their current coverage policies on bariatric surgery. But overall I'd say your contract is good news, because bariatric surgery isn't excluded. If they deny based on something other than your medical criteria you'd have an EXCELLENT case for appeal.

[mylapspirit 2]

Hi! The key here is Blue Cross/Blue Shield. They will do everything possible to not cover it but if it is not excluded on your policy they eventually WILL cover it - just don't give up. It took me 11 months to get approved. I just got approved last Friday. I started the process in August 2006. Jump thru all the hoops they ask of you. Don't give up, be persistant and patient. Work with the insurance coordinator at your surgeons office. Never give up!

Michelle:ranger:

[valzie 0]

I just read someone else on this site got approved within two days of submitting to bc/bs so it all depends on the bc/bs company.

[Alexandra 55]

I am concerned because under exclusions, it says that it excluded treament of obesity yet the above clause was in the covered benefits- It's like they are contradicting each other.

Ahhh, yes, but "medically necessary" is the magic phrase here. Obesity in general is not considered to require medical treatment (which is why such treatment is excluded on almost all medical plans), but morbid obesity is. The clause you copied says "medical necessity...as defined by us" so call them and get a copy of what they consider the definition to be. I'd be shocked if it didn't exactly mirror the generally accepted medical definition of severe or morbid obesity: a BMI of 40 or above, or a BMI of 35-39 with accompanying comorbidities. With a BMI of 46 you definitely qualify under medical guidelines, and if they say you don't, again, you'd have an excellent case for appeal.

As for it being BCBS, one BCBS is not the same as another. Each state has its own, as well as its own rules about what can and can't be excluded.