Momentary excitement - but still waiting.

[ReneBean 3]

OK folks - You may or may not have seen reply posts from me regarding the evil insurance company - Blue Cross.

I called prior to starting the pre-work for the band to be sure that there was no company exclusion - and was told that there was not.

When my Lap-Band coordinator called, SHE was told that there was.

GRRR.

OK - the point of this post? It's all in HOW you ask the question. The following is an excerpt from the e-mail I got from Blue Cross of CA:

"I've looked into the ... contract further and their is an exclusion but their isn't.

Please see below explanation. I think the customer service rep the provider spoke to didn't go into enough detail or perhaps there was a misunderstanding. Per the group's EOC, page 26, Obesity is listed as a exclusion, however, if you read further, it's clear that the exclusion does not apply to morbid obesity.

**************************************this is the eoc*******************************************

Per EOC:

OBESITY. Services primarily for weight reduction or treatment for obesity.

This exclusion will not apply to surgical treatment of morbid obesity as determined

by us if we authorize the treatment in advance as MEDICALLY NECESSARY and

appropriate.

***********************************************************************************************************

So the first sentence is the exclusion = Services primarily for weight reduction or treatment for obesity.

But then the next sentence says;

This exclusion will not apply to surgical treatment of morbid obesity ..and so on.

This means that going to a weight doctor is not payable just to lose weight. But if surgery is involved, then we determine if medically necessary and then approve or deny the surgery. And yes lab band surgery is payable now as long as member meets criteria which I believe in part means the member's BMI is 35 or above (don't hold me to that)."

Obesity = NO. MORBID OBESITY + Medical Necessity = Yes.

So, I am back on track and REALLY excited.

Of course, I still have to wait for the paperwork to clear and get that first decision.... *sigh*

[Alexandra 55]

Yep, that's standard language in most contracts, actually. This is exactly why it's so crucial to prove medical necessity...that is, to "qualify" for the surgery. Below certain medical criteria no insurance carrier will pay for bariatric surgery, but above those levels most will (unless there is an employer-dictated exclusion).

Signals look good...Good luck!!

[HotLikeHer 0]

that is what mine said too, I have BCBS Empire,,, Usually if you have a BMI under 40, then you would have to have co-morbidities.

I have sleep APnea, just diagnosed in July, Insulin resistance, as far as my insurance was concerned the same as a diabetic, since I take the same meds, Poly Cystic ovarian Syndrome and even my Mitral Valve Prolapse was one since the heavier I am the more blood volume needed etc, and the harder the heart works, etc....

I am 5'6" 225 lbs

well 218.5 since I started the Optifast diet on the 16th...

Great news, Good luck on this