Question:
What are the chances for approval?
I have BCBS fo TX. In my benefits booklet under Limitations & Exclusions it states the following: (The benedits as described in this Benefits Booklet are NOT available for): 1. Any services or supplies which are not Medically Necessary and essential to the diagnosis or direct care and treatment of a sickness, injury, condition, disease, or bodily malfunction; or any Experimental/Investigational services and supplies. ....blah, blah, blah....... (Clause #24) 24. Any services or supplies provided for reduction of obesity or weight, including surgical procedures, even if the Participant has other health conditions which might be helped by a reduction of obesity or weight. I think "Medical Necessity" and the fact that "Morbid" obesity is NOT specifically stated are key factors in approval. What do y'all think? Does anyone have a similar Exclusion? Has anyone beaten an Exclusion like this before? At my place of employment, BCBS is the only insurance offered. We have a choice of HMO and PPO. I have the PPO. What do I do? I really want this surgery. I have an appt. set for consultation but can not get in to see the dr until Feb.14, 2001. — H L. (posted on August 4, 2000)
August 4, 2000
I insurance company said almost the same thing to me. That I either had to
have a heart problem, diabeties, or hypertension in order to be covered. I
also think it is stupid but I am going to appeal this denial and check with
my PCP again to see if we haven't over looked anything. I was on Pondimin,
Redux and Phen-Phen, and I didn't ever tell my PCP that I was on it when I
started to get into having this surgery. Now that I have been denied and
haven't had an EKG or had my heart checked I may have this problem. Good
luck in whatever you do and hopefully we both get our surgeries before it
is too late. I know we need it.
— Chantee R.
August 4, 2000
Hi,
Mine said the same thing. My doc was able to convince the insurance that I
needed the surgery. Talk to your doc about this. I am six months today
and have loss 80 lbs. Good luck.
— Lee Ann B.
August 4, 2000
If you do get approved please let me know how. I have been fighting BCBS
of LA going on two years and denial exclusions listed the same way. But I
think Texas recognizes Obesity as a disease where LA does not.
— Nancy B.
August 4, 2000
Texas is no Different than Los Angeles as far as BCBS is concerned. It is
like Ray states it depends on what the Employer wants to cover in the
policy. I was told where there is an Exclusion it is a crap shoot 50/50
chance of getting approval.
— Tamaria W.
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