Question:
Any hints on getting approved with a SELF-FUNDED EMPLOYER?

Our insurance is through the city, which is self funded..our processor is BCBS of Tx and Ive been denied 2ce now. My PCP says the WLS is "medically necessary", with type 1 diabetic & sleep apnea. Any ideas on how to go about this? Thank you for your time.    — Traci P. (posted on November 16, 2003)

November 16, 2003
Traci, I don't want to discourage you - but I've never yet heard of a self-funded - particularly BC/BS policy - covering WLS. I went through two denials (two different insurance companies) myself, so I totally know what you're going through. Have you considered self-paying? I went to Spain for my surgery (www.bodybybaltasar.com) - and with surgery, travel, everything, it was $15,800. I've lost ALL of my co-morbidities and 183 lbs in the past 16 months. I have an incredible surgeon - who is so cool, and loves his patients and is committed to life-long follow up. I have a friend who lives in Texas and also went to Spain for her surgery last February (I got to go with her to be her angel) - maybe she could answer some questions for you - I know she knows an awful lot about the system in Texas. Blessings, dina
   — Dina McBride

November 16, 2003
I have heard of a self-finded policy administered by BCBS approving WLS. As a matter of fact other than my deductible and co-pay for the year they covered everything but $101 of the anesthesiology bill. Mine was a point-of-service contract and therefore there were no agreements in place with providers. They also just gave me an approval to have abdominoplasty done in 2 stages. Personally I think the self-funded policies tend to be more flexible and cover many things a standard policy doesn't. Granted they could have an exclusion in there. <p>Exactly why are they denying you? What did the letter say? Look at your benefits booklet in the exclusions section and look for where it addresses treatment for weight loss etc. Unless it clearly says that there is no coverage for Morbid Obesity and disease etiology, then you should be able to get it approved. Mine says there is no coverage for weight loss programs, drugs etc. except in the case of morbid obesity and disease etiology. My approval went through rather quickly. Please feel free to e-mail me with what your letter says and I'll see if I can give you any pointers. I've been dealing with BCBS for 15 years, have taken them to claim appeal and won and am batting 100% on getting things approved. Not without some getting upset on my end, but still managed to do it. I'll give you whatever feedback I can.
   — zoedogcbr

November 16, 2003
I have a self-funded insurance (although not BCBS) and it covered my RNY 100% and has approved my breast and arm plastic surgery too! So, YES it can happen. What I did was quote the insurance book and their own definition of morbid obesity in my letter that was submitted to them. E-mail me and I will send you a copy of what I put together for them. I was approved relatively quickly with the massive amounts of documentation that I provided them. :-) Good luck to you in your journey. Sharon
   — Click

November 16, 2003
Definition of a self funded policy---Your employer, the city, pays for all of your medical expenses, they are the ones that write the policy, and they are the ones that approve or deny EVERYTHING. BX is only there to process your claims. They pay for all of the claims out of your employers check book. At this point, you approval has NOTHING to do with BX, they only follow the rules that your employer has told them to follow. That being said, if you were denied due to an exclusion, nothing short of getting a different policy will usually help this type of situation. Some times employees can plead their case to the employer and get policies changed, but in your case you are dealing with a GIANT entity and most likely will not get far in your endeavor. Are you married? Does your spouse have insurance available to them? Those are other options other than finding a new job, which I'm sure you dont particularly want to do. I wish the best of luck to you, exclusions for WLS should not be legal. IMO
   — RebeccaP

November 16, 2003
Rebecca, Everything you say is right but it is important to be absolutely sure there is a written exclusion. Do not assume BCBS has interpreted things correctly. Would not be the first time. Make sure it is written in hard granite right in the policy booklet and if not appeal till you are blue in the face is my feeling. What do you have to lose, besides lots of weight.
   — zoedogcbr

November 16, 2003
Her profile states there is a written exclusion, that was the basis behind my comment. I'm going to climb up on my soapbox here a minute. I think it is pathetic that any company or insurance company would exclude this sort of corrective action. Oh nevermind, we all feel the same way. LOL You know what I mean....I just get so angry when something this specific is intentionally excluded. It is a finacially motivated exclusion, and thats wrong.
   — RebeccaP

November 17, 2003
My company is also self insured. I was approved immediately after the paperwork being submitted. My brother who is an insurance agent told me in his opinion it is much easier to be approved when your company is self insured. Most times the company will provide whatever care the employee needs. I've also been told by my company just because the policy language says there are exclusions does not mean they can not be review and approval given. In my situation all that needs to be done is a visit to the VP of HR. If a reasonable claim is made they will overturn the denial. Now your situation is different as you are dealing with City Government. I say fight on, you may be pleasantly surprised.
   — D L.

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