Question:
BCBS PPO - Blue Choice n Consult was not paid for, does this mean WLS is excluded?

Hi, I just got the thing in the mail that BCBS sends you after you have a Dr. visit and this one was for my consult. It said I was responsible for paying the whole consult and under remarks it said "YOUR CONTRACT EXCLIDES THIS PROCEDURE OR CONDITION AS A COVERED BENEFIT" Does that mean the consult or WLS? As far as I know, they do cover it. I mean even when we got our ins. booklet, there was a seperate page with an endorsement for WLS unless you had had it done before. I called BCBS before I went to this consult and they said I could go see a surgeon and that they decide after all infor is turned into ins. if medically necessary, I am so confused and upset. Of course, they aren't there until Monday and I think I'll be a basket case by then. Maria    — Maria S. (posted on May 4, 2002)

May 4, 2002
My insurance would not pay the Consult fee either, but paid for surgery, I think the insurance companys do not look at a consult as treating an illness, Do not worry This does not mean they will not pay for surgery Best of luck
   — Jeri P.

May 4, 2002
I have the same insurance you have it should pay for the consult once your surgery is approved and good luck with the approval---I have fought BCBS of FL since Nov 2001 I have just hired Walter at Obesity Law---everytime you meet their requirements--the put another one out--and it is top secret what the requirements are for medica necessity---read my profile and get in contact with me if you like.
   — Linda L.

May 4, 2002
I have bcbs ppo and they paid for everything with out any problems so far . I got my bills from them last week and out of over 39,000 I only have to pay 100 They gave approval the very day my dr called and they have been easy to work with so far . I have a bmi of 40 but i am diabetic and have some other medical problems . I wish u sooo much luck :-)) I am sure all will be ok
   — sallie P.

May 4, 2002
Maria, how can they refuse to pay for it, when at this time they apparently haven't received any information from your PCP or your surgeon concerning their opinion as to whether you need this surgery. They have no info to establish whether your case meets their medical criteria or not. Call BCBS, ask to speak to the person that you spoke to concerning this, they will take your name and number and have that person return your call. ( I do it, I only wanted to deal with one person in customer service, so while I had a lady on the phone, I asked her if I had further questions or problems could I call and ask to speak to her. She said I'd have to leave my name and number, and she would call me back, so far this has worked out, I hope you noted the name, date and time of who you spoke with) When you reach her/him ask why it was not covered, medical necessity hasn't even been established up to this point. If I can help, Email me, [email protected] Jo-Dee Hortz
   — tinyjo

May 4, 2002
Maria..Don't worry. I got the same Explanation of Benefits after my first visit to surgeon, but then 3 weeks later got a letter in the mail approving my surgery! I just had the billing person re-submit the bill and it was paid within a few weeks. I had BC/BS of AL PPO plan. Good luck to you!!
   — Jennifer C

May 5, 2002
My husband and I work for Blue Cross of PA (Independence Blue Cross) I have the PPO coverage with them. My husband actually is a Member Service Rep in the PPO department. When I started researching WLS I was shocked that the initial consult wasn't covered. My husband assured me that the consult is an exclusion, however, they do cover the surgery as long as it is medically necessary. I made an appointment with a surgeon in my area and asked how much they charge for the consultation. The office manager assured me that our insurance has started to cover this fee. So of course I went back to my husband (because he is the expert in this matter) and he told me that it is an exclusion, but if the surgeon doesn't use Morbid Obesity as a diagnosis code, then the insurance company would pay without question. So it all boils down to how the office bills for the consultation. I hope this helps.
   — amd0721

May 6, 2002
I have BC/BS PPO (Anthem out of Indiana/Ohio) and they covered my initial consultations. Had major trouble getting approved for surgery though. From what I understand from my experience and policy, they covered office consults, lab work, etc., as long as it was billed under the co-morbidities and not just as morbid obesity. In fact I had a denial on some pre-op testing (ekg) that was originally denied because the diagnosis submitted was weight loss. The real reason they did the ekg was because of my history of high blood pressure and cholesterol, and the surgeon wanted to check my heart to make sure I would be able to handle the surgery. When I talked to the insurance company, they told me they would cover it if it was submitted under a diagnosis code of High Blood pressure, which I talked to the Dr.'s office and they are resubmitting. Be sure to advice the doctors billing dept. that they need to use relevant co-morbidities for the diagnosis, not just weight loss or obesity.
   — Dell H.

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