Exclusion?

Mellie · July 22, 2005

I have blue cross blue shield blue options. They do cover WLS surgery if medically necessary, but they have an exclusion for adjustable gastric banding. They cover the RNY and other surgeries. Is there any way I can fight an exclusion? Also, I was looking up the codes on their website and they do have a code for adjustable gastric banding. Which makes no sense to me if they have it excluded from coverage. Can anyone help me with this?

FRECKLES3 · July 22, 2005

I Work For An Insurance Company And The Plans We Have An Exclusion Means The Employer Chose Not To Offer That Option

the best me · July 22, 2005

The code for Lap Band Surgery is a nationwide medical code and all insurance companies know it and use it. It's all a part of standardized medical billing. So when you look it up, it will show it, and your particular plan will state whether or not/how it's covered. My BCBSNC Blue Options has the same exclusion for Adjustable Gastric Banding. I saw this and looked straight into self-pay, knowing all the hoops to jump through would be time-consuming and aggravating. I know I don't have the patience and tolerence for that. It was worth it to me to be able to schedule my surgery in a month or two and just "git 'er done!" and just pay for it.

That's me though. What might get suggested here is to have your Bariatric doc submit all the necessary paperwork for the Banding, let them deny the claim, find out why they are denying, and if it's able to be fought, it will most likely be able to be won. For example, if they deny the claim stating that AGB is experimental, many a ruling has been overturned when the documentation proving it's NOT experimental can be submitted. Inamed has packets available for this sole purpose, if I understand correctly. If your doc's office has experience with dealing with denials, they can be a great resource.

On the other hand, if it's something that just isn't covered, no matter what, simply because your plan doesn't cover it, I'm not sure what you'd do. Change insurance companies, if possible. Find out about changing plans. Find out what BCBS plan DOES cover AGB-if any-and change it? Maybe you will get better advice from others here.

All this frustration and mess is what I saw ahead of me. I thought, ya know? in the 2 years it could take me to get all this done and fight it and wait and wait, I could be banded and at or near my goal weight!!! And I KNEW RNY was NOT an option, no matter what. Thankfully, hubby agreed. So here I am, getting on with it.

Good luck. Keep pressing forward!!!

Alexandra · July 22, 2005

Mellie, Kathy is exactly right. When you say "they" have an exclusion, whose exclusion is it? That's the first step to figuring out whether you can go around it or not. Good luck!!

Mellie · July 25, 2005

Thanks everyone for all the ideas and support. I just feel lost sometimes and overwhelmed with the process of getting this done. It helps to have someone to talk to.

Joyce in VA · July 26, 2005

Mellie,

You might also check with your doctor about financing the surgery. Some have a plan. I don't know what the requirements are. Just a thought. Good luck.