"Categorically Excluded" - Did I assume wrong?

[forgetit 11]

I have BCBS of Alabama, but apparently only their super high leveled plans will cover WLS at all. I was told that under any and all circumstances that surgery is "categorically excluded," meaning no chance at all that they would cover. I've already had my surgery, paid for with CareCredit and the help of some friends, but I'm seeing all this stuff about appeals and the like and wondering if I was stupid to assume I was just out of luck with insurance and just went $16,000 in to debt for no reason...

[NikkiDoc 312]

Ask for a copy of the policy and have them point out the specific exclusion for WLS. Many policies have a hard and fast exclusion that weight loss surgery is flat out excluded. No amount of appeals will override that type of exclusion. However, I would want to see that Policy in black and white to read it for myself. Customer Service and HR at the employer make all kinds of errors.

[OutsideMatchInside 10,166]

Alabama is a state that WLS surgery is not considered an essential service. They don't have to cover it by state law, so they won't.

http://nofusa.org/news/health-insurance-cover-obesity-treatment/

Edited November 2, 2015 by OutsideMatchInside

[BLERDgirl 6,417]

It doesn't matter. The insurance company is not going to reimburse you and finding out you *might* have gotten it covered through appeals is only going to piss you off. Just keep in mind going forward, most insurance companies have appeals processes.

[2goldengirl 2,076]

I'm afraid you're out of luck if it is a specific exclusion. An appeal can't create a benefit where none exists.

That said, if your insurance is employer-sponsored, once you've got your BMI down to a healthy level and are off medications, etc., go to your HR benefits people and show them how much less you are costing in health care costs now that you're healthy. Alabama is a state with a very high rate of obesity, and obesity-related illness. Things won't change without input like yours. You may be able to help others in the future.

Nearly 20 years, ago, I was in a meeting and our Chief Medical Officer was going on and on about diseases we needed to focus on managing to make a positive effect on long-term outcomes. As you might expect, they were things like diabetes, heart disease, hypertension, and I forget what else. I worked for a health plan at the time.

I stuck my hand in the air and said "So, what you're really saying is, if we focused on treating obesity, we'd have better outcomes for all of those."

He flat out told me "well, that isn't going to happen." Ha! Guess who was right?

[Champ715 207]

I have BCBS of Alabama and was approved just by meeting the criteria they list here:

https://www.bcbsal.org/providers/policies/final/053.pdf