WLS exclusion from BCBSF

I am 33 with a BMI over 40. I have hypertension and currently taking 2 different medication and is still uncontrolled. I have borderline diabetes and cholesterol. I have completed the required prerequisites to qualify for weight loss surgery. About 7 months ago I called BCBSF and I asked if WLS was covered under my plan and the answer was "yes and no". The rep stated that there was no specific provision in the policy that covered WLS, but the doctor would need to provide a letter of "medical necessity". I have an out of pocket of $4500, and I have met $3800 already. I am doing my endoscopy later this month and my surgery date is scheduled for the day before Thanksgiving.

My question is has anyone been told their surgeon was required to submit a medical necessity form in order to be considered for approval?

When you say you've "completed the prerequisites," is that for the SURGEON? Or for the insurance company?

If you haven't yet, you need to get something in writing that says what you'll need (documentation and medical conditions) in order for the insurance company to approve payment.

Many surgeons won't even schedule surgery until things have been submitted to the insurance company and insurance comes back with "yes, we'll pay for this." I know there have been more than a few people on the board here who've assumed insurance was OK, had surgery, and found out afterwards that they weren't covered... leaving them on the hook for $10k+.

So far I have had the 6 month supervised diet with nutritionist as per BCBSF along with TSH indicating no thyroid issue. I have seen a psychiatrist that has determined that I don't have a eating disorder. My primary doctor has provided my surgeon with years worth of failed attempts with prescription medication to control my blood pressure.

Sounds like you've got most of the major stuff down. Do you know if this info has been submitted to the insurance company for approval? Or if your surgeon is currently hanging on to it?

I have HighMark Blue Shield. They also required a letter of medical necessity from my PCP to get the approval process started. It appeared to be just another rubber stamp among many others in the approval process. Not a big deal, at least in my plan.

psychoticparrot

How long did it take from the time your office submitted the documents til the time you were approved?

Vanessa, I have BCBSIL...what I did was I went to my surgeon and his office built a case for the insurance approval. I started the process June 4th and I am 1 week out of surgery. The process seems very fast....I have paid my out of pocket which was $4000. Funny thing though...BCBS just sent me a letter telling me the insurance plan that I have is be discontinued and as of Jan. I will have to choose an new plan...I'm self-employeed.

Thank god you got the procedure out the way. I hope some day Congress/politicians realize that we are facing an epidemic and require all insurance company to allow wls as a covered benefit

I have heard from a few people that has BCBSF that it all depends on the person at the insurance company that is handling your case. A few years ago I had a BR that was fully paid by BCBSF. When my surgeon at the time submitted my documents for the BR the approval took less than a week. I had a coworker that also needed to have a BR and I recommended my surgeon and she met the criteria and was denied.

Did anyone require an endoscopy before the procedure?

An endoscopy is very common before weight loss surgery.