BCBSTX approved now refuse payment!

[uberbuffaloegal 13]

I am beside myself with worry! I was sleeved March 7. I was approved by my insurance, I and my doctors office have approval letters. The insurance company now says VSG is not covered by my insurance plan. I NEVER would have had the surgery of it was not covered. They say I owe $42,000! They are even refusing to pay pre op tests and labs. Has anyone else had this happen? Did they have to pay? Am I up the creek without a paddle?

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[2goldengirl 2,076]

I can't understand how they would hold you responsible when they approved you having a procedure that they approved - checking to assure you had the benefit was part of their job as part of the approval process!

[kmorri 1,689]

Do you have a copy of your approval letter? did they approve the specific procedure or just WLS in general? Your doctor should be preparing an appeal....Contact them (surgeon) and ask if in their request for approval they specified which procedure they were doing.....ask them if they are submitting an appeal......Try to not stress, I work in the insurance business and I think you'll be okay....The most important thing is did they request approval for the specific procedure, and I can't imagine getting an approval if they didn't do that....The only problem would be if they got an approval for one procedure but they performed something different.....Your insurance didn't have any changes after your approval did it? You can also call your insurance company and ask why it was denied after being pre-approved, but your surgeon will probably have better luck because the appeal will require all the medical records and such.... Best of luck!.....

[kmorri 1,689]

Also, I noticed your profile say's you're in CA....but you mention BCBS of TX. If you're coverage is with the TX plan but your surgery was done in CA, the claim will be processed by the CA plan but using the Texas guidelines....through a program referred to as "BlueCard" It's possible the wires got crossed between the two plans.....call your plan and ask for a supervisor......an upset member calling sometimes is all it takes.......but upset, verses mad will work much better.

[uberbuffaloegal 13]

Thanks for your feedback! I do have my approval letter and it is for a vsg with my doctor on March 7. Apparently the problem is my plan doesn't cover weight loss programs or things related to obesity but it does cover bariatric surgery. So they're denying it because it was for obesity even though the guidelines to get bariatric surgery a BMI of 40 is what is required. Luckily I also have severe sleep apnea, and they may cover it under that. The doctor's office is talking about partial coverage so I may have to get an attorney and see if I have a leg to stand on.

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[kmorri 1,689]

Still sounds like a mess. hopefully it'll all get straightened out....the good thing is you've already had your surgery and they can't take it back... :-) I still feel positive about your situation. Surely it's just a misunderstanding somewhere. Keep us updated. Good luck!

[2goldengirl 2,076]

Oh for pity's sake, the only reason to DO bariatric surgery is for obesity.

You didn't say which state you're in Ca, or TX. If you are in CA, if this is a P P O plan, contact the State Department of Insurance.

[kaitlynm 335]

I also have BCBS of TX which does not cover any obesity related conditions but they do cover WLS. Your plan is picked by your employer but it sounds a lot like mine. They did not cover the NUT or the psych eval, but so far have covered everything else for me. I had my surgery last Oct. generally if your plan changes it does so on Jan 1. Did you get approved before the first of the year? It sounds like there is just a mix up, and I'm sure they will get it fixed. I had trouble with my PCP regular appointments for a while because he would put the obesity code on the visit even though that wasn't what I was there for and BCBS kept denying the claims. He resubmitted with the correct code and they covered everything.

[uberbuffaloegal 13]

Hi all,

You know @@kmorri, that is exactly what I thought I am so happy I got my surgery. Even if I have to keep driving my 17 year old car and hold off on buying new I, so be it:)

2goldengirl, I know huh, duh, obesity, why cover it if not for obesity! Thanks for tip on insurance board, I am in CA.

Kaitlynm, thanks for sharing your experience, I will talk to doctors office again tomorrow and see what they are doing. Crazy thing is they covered NUT and psych eval, I wonder what code they used. But not covered labs, lung xray and ekg

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