My Insurance Policy

[Daisalana 33]

Just to see what they would cover in the future (plastic surgery, emergency removal), etc.. I decided to actually read my BCBS of AL policy. I called them pre-banding and they said no obesity treatment, but I never read my policy, I took it for what they said.

So anyway, I am hoping for no more complications, but.. I wanted to see if I decide to get PS for my thighs (my gyno recommended it even) for the problems I have with them..

I am hoping anyone that knows anything would consider PS a requirement based on what my policy says.

It lists this first--

"Health Benefit Exclusions"

4. Services or expenses for costmetic surgery. Cosmetic surgery is any surgery done primarily to improve or change the way one appears. Reconstructive surgery is any surgery done primarily to restore or improve the way the body works. Reconstructive surgery is covered;cosmetic surgery is not. Complications or later surgery related in any way to cosmetic surgery is not covered, even if medically necessary.

a. (nothing important)

b. Some surgery is always cosmetic such as ear piercing, neck tucks, face lifts, buttock and thigh lifts, implants to small but normal breasts.

(How can that always be cosmetic? Due to the fat/skin on my thighs, no matter what treatments I've tried from doc recommendations, I have disfigured and painful sores on my thighs..that get infected, etc.)

So then..

Exclusion #55. Services or condition including, but not limited to, obesity, diabetes, or heart disease, which is based upon weight reduction or diet control. This exclusion includes Bariatric Surgery & Gastric Restrictive procedues and any complications arising from Bariatric surgery & gastric restrictive procedurs.

So with this information, do you think they would cover having a pannus (sp) removed?? And I don't know if what I need for my thighs is called a thigh-lift?

[juliegeraci 7]

To me it sure sounds like it will not be covered. Especially since you had Bariatric Surgery.

[Joule 0]

Hi FairyFacade....My BC/BS insurance policy reads the same. What made you decide to do the surgery knowing you don't have coverage for complications?

[QTkidsmom 0]

I have worked in managed care for more than 20 years and must say that the EOC (evidence of coverage) usually lists more procedures under the exclusions than the plan will actually deny.

You see, they CAN pay for more than they say they will if they have a policy to administer the coverage equally among their insured, or have good reason for making the exception. But, if they don't offically exclude it, they open themselves to having to pay for it.

The coverage guidelines, intended for internal use and for the providers and delegated authorizing entities, would be helpful here. Good luck with that though, your best chance of getting it covered would be to have the doctor submit a request for the service with support of medical necessity. If it is denied, you should receive appeal rights (could vary by state). Usually, if it is denied and your appeal is upheld it will go to a 3rd party for a final decision (again could vary by state).

Out of curiosity, did they cover your surgery or were you self pay? If they covered they surgery, that is a good indication that they may consider PS. Especially since, based on what you posted, your policy shouldn't cover WLS period.

I have BC of CA (HMO) and they covered my surgery. They will also cover ab-plasty if certain requirements are met, after surgery. Plans vary greatly, even within the same insurance company. It really comes down to the individual policy you hold.