no clue what to do

[Kerryp22 2]

I just got my paper work for my seminar next week... so i see I had to call my insurance BCBSTX , they tell me my plan doesn't cover it.... even with health issues, I have numerous weight related health issues eg) diabetes, hypertension etc . IM absolutely gutted. I don't no what else to do.?... i can't pay out of pocket. I guess this just isn't going to happen...

Wishing each of you every success

[Foxbins 625]

Appeal the decision. Talk to your doctor, they should help.

[Kerryp22 2]

3 hours ago, Foxbins said:

Appeal the decision. Talk to your doctor, they should help.

Thank you so much for your reply. I appreciate it. So I haven't put in anything yet to appeal it, I just rang to see if my insurance covers it (as the packet I recieved said to do so) the insurance company said they don't? So im not sure what to do really. Is there any point in going to the seminar? I finally after 20 years ask for help and I get hit with this.... im just so upset

[mcfluffington 179]

This seems odd to me. I switched to BCBS in order to get this surgery. Mine is out of Illinois. Try another call. Maybe you will get another answer. Is there any way you can switch to another insurance? Where I work we have two alternatives Aetna and BCBS. but then I work for a large multinational. Definitely get your docs team to call they should be very helpful in this if they want to get paid.

[billho 245]

Have you looked at your policy? if WLS is not covered, it should be mentioned in the excluded services section. I have delayed my surgery a few years because I had Aetna- Aetna usually covers it, but my specific policy had an exclusion for any weight loss stuff. No amount of appealing or letters from my doctors would change that.

Earlier this year, Aetna raised their rates to an insane amount, so I switched to my wife's insurance and I finally have coverage for surgery.

Hang in there. Sometimes insurance companies don't think this through, as it has been shown that their costs will go down in the long run if you lose the weight and a lot of the other conditions you have improve.

Edited September 18, 2020 by billho

[catwoman7 11,212]

2 hours ago, mcfluffington said:

This seems odd to me. I switched to BCBS in order to get this surgery. Mine is out of Illinois. Try another call. Maybe you will get another answer. Is there any way you can switch to another insurance? Where I work we have two alternatives Aetna and BCBS. but then I work for a large multinational. Definitely get your docs team to call they should be very helpful in this if they want to get paid.

employers don't always use the standard policy - they can include or exclude coverage of various procedures for their employees. Some don't include the bariatric surgery coverage because it makes the policy more expensive. My insurance didn't cover bariatric surgery until this year, even though some other companies that used this same insurance for their employees DID include bariatric surgery. So when I had surgery five years ago, I had to switch to a different (more expensive) company for a couple of years, and then switch back.

[catwoman7 11,212]

it'd be worth following up on, but if it's an excluded service in your particular policy, you may be out of luck. I had to switch insurance companies for a couple of years to have it done.

[BigSue 1,370]

It is quite possible that your insurance does not cover WLS under any circumstances, regardless of BMI or comorbidities. If your insurance is through your employer, the employer can choose whether or not to include WLS coverage. But that doesn't mean you need to give up on ever having WLS. Here are some options:

• Change insurance. If you have a spouse who has insurance through a different employer and your spouse's insurance does cover WLS, you could get on your spouse's insurance. Even if the premiums are more expensive, it could be worth it to get the WLS coverage. Or you could try to find a different job with better insurance (easier said than done, I know, but depending on what type of work you do, it may be feasible).
• Self-pay for surgery. Shop around with different surgeons. They will often have lower costs for self-pay patients than what they charge insurance, so make sure to tell them you'll be self-pay. The advantage to self-pay is that you don't have to jump through as many hoops as the insurance companies require, so you can get surgery sooner. There is a place called Blossom Bariatrics in Las Vegas that specializes in self-pay patients, so you might want to check them out.
• Medical Tourism. A lot of people go to Mexico for WLS to save money. It costs less than surgery in the US even with travel. There are some risks to it, but a lot of people have great experiences with WLS in Mexico. I saw somebody post about it a couple of weeks ago who only paid about $5000 out of pocket, which is almost as much as I paid out of pocket with insurance coverage.

Does the seminar you planned to attend cost any money? In my program (and many others), the informational seminar is free, and in that case, it wouldn't hurt to attend just to learn more about the surgery. If it costs money, though, you can get the same information for free online.

[Walter Lindstrom 42]

BCBSTX offers many plans depending on the employer type (large or small group, individual, state plan, unions, etc.) - some cover, many don't (sorry). Since you haven't had a preauthorization request sent to them yet, there is nothing that's been denied. This gives you time to locate your Certificate of Coverage or Summary Plan Description - the long booklet (usually 100 plus pages and not to be confused with a "Summary of Benefits and Coverage") so you can look for yourself as to what is / is not covered. We're coming up to the end of the year so you ought to see if your benefits change to a new payer or plan type on 1/1/2021 if you don't have coverage. Contact us if you want some free help with the process - Kelley will be happy to guide you in the hope it leads to an approval. Good luck!

[Kerryp22 2]

On 9/18/2020 at 5:50 AM, mcfluffington said:

This seems odd to me. I switched to BCBS in order to get this surgery. Mine is out of Illinois. Try another call. Maybe you will get another answer. Is there any way you can switch to another insurance? Where I work we have two alternatives Aetna and BCBS. but then I work for a large multinational. Definitely get your docs team to call they should be very helpful in this if they want to get paid.

Unfortunately my plan doesn't cover it 🤷‍♂️

[Kerryp22 2]

On 9/18/2020 at 8:48 AM, catwoman7 said:

employers don't always use the standard policy - they can include or exclude coverage of various procedures for their employees. Some don't include the bariatric surgery coverage because it makes the policy more expensive. My insurance didn't cover bariatric surgery until this year, even though some other companies that used this same insurance for their employees DID include bariatric surgery. So when I had surgery five years ago, I had to switch to a different (more expensive) company for a couple of years, and then switch back.

thank you very much for your reply

[Kerryp22 2]

15 hours ago, Walter Lindstrom said:

BCBSTX offers many plans depending on the employer type (large or small group, individual, state plan, unions, etc.) - some cover, many don't (sorry). Since you haven't had a preauthorization request sent to them yet, there is nothing that's been denied. This gives you time to locate your Certificate of Coverage or Summary Plan Description - the long booklet (usually 100 plus pages and not to be confused with a "Summary of Benefits and Coverage") so you can look for yourself as to what is / is not covered. We're coming up to the end of the year so you ought to see if your benefits change to a new payer or plan type on 1/1/2021 if you don't have coverage. Contact us if you want some free help with the process - Kelley will be happy to guide you in the hope it leads to an approval. Good luck!

thank you for your reply! So I contacted Another person. They stated I need a "determination" so I guess its a chance?

[Kerryp22 2]

18 hours ago, BigSue said:

It is quite possible that your insurance does not cover WLS under any circumstances, regardless of BMI or comorbidities. If your insurance is through your employer, the employer can choose whether or not to include WLS coverage. But that doesn't mean you need to give up on ever having WLS. Here are some options:

• Change insurance. If you have a spouse who has insurance through a different employer and your spouse's insurance does cover WLS, you could get on your spouse's insurance. Even if the premiums are more expensive, it could be worth it to get the WLS coverage. Or you could try to find a different job with better insurance (easier said than done, I know, but depending on what type of work you do, it may be feasible).
• Self-pay for surgery. Shop around with different surgeons. They will often have lower costs for self-pay patients than what they charge insurance, so make sure to tell them you'll be self-pay. The advantage to self-pay is that you don't have to jump through as many hoops as the insurance companies require, so you can get surgery sooner. There is a place called Blossom Bariatrics in Las Vegas that specializes in self-pay patients, so you might want to check them out.
• Medical Tourism. A lot of people go to Mexico for WLS to save money. It costs less than surgery in the US even with travel. There are some risks to it, but a lot of people have great experiences with WLS in Mexico. I saw somebody post about it a couple of weeks ago who only paid about $5000 out of pocket, which is almost as much as I paid out of pocket with insurance coverage.

Does the seminar you planned to attend cost any money? In my program (and many others), the informational seminar is free, and in that case, it wouldn't hurt to attend just to learn more about the surgery. If it costs money, though, you can get the same information for free online.

seminar is $25. Im attending it next week. I called a different person at BCBSTX they stated I need a "determination"? So I'm assuming I may have a slight chance?

Thank you so much for your reply

[Kerryp22 2]

On 9/18/2020 at 8:50 AM, catwoman7 said:

it'd be worth following up on, but if it's an excluded service in your particular policy, you may be out of luck. I had to switch insurance companies for a couple of years to have it done.

Thank you for your reply

[Kerryp22 2]

On 9/18/2020 at 8:43 AM, billho said:

Have you looked at your policy? if WLS is not covered, it should be mentioned in the excluded services section. I have delayed my surgery a few years because I had Aetna- Aetna usually covers it, but my specific policy had an exclusion for any weight loss stuff. No amount of appealing or letters from my doctors would change that.

Earlier this year, Aetna raised their rates to an insane amount, so I switched to my wife's insurance and I finally have coverage for surgery.

Hang in there. Sometimes insurance companies don't think this through, as it has been shown that their costs will go down in the long run if you lose the weight and a lot of the other conditions you have improve.

Thank you so much for your reply.

I called another person at BCBSTX and they said I need a "determination". I gave them a CTP code so she could check it out! I guess its a slight chance?