Question:
I have BCBC (point of service) they have a written exclusion for weight loss surgery
I was told to self pay and then send in claims. They said they would be denied, then I would appeal. Has anyone gotten this type of insurance to change their mind and pay? — juanita F. (posted on September 24, 2003)
September 24, 2003
It is very hard if not near impossible to get written exclusions
overturned. You could be stuck with a huge bill.
— Delores S.
September 24, 2003
I'm in one of the BCBS plans. I initiately thought I wasn't covered
either. Ask the customer service rep specifically what cover you have if
the diagnosis code for morbidly obese is used. In my case, that was the
exception to the exception.
— rleffler
September 24, 2003
I had BCBS and they had a written exclusion and absolutely WOULD NOT budge
no matter what I done. Sorry.... I wish you luck.
— CARLA C.
September 24, 2003
It is unusual that the BCBS POS plans would have the exclusion if MO. The
POS plans are the most expensive and those usually cover it. Get out your
insurance booklet and look in the exclusions section. There will be an
item that addresses weight loss programs etc. not being covered except in
the case of MO and disease etiology. If it reads like this, and you
qualify by the NIH guidelines, then it is likely your ace in the hole. If
it does read this way then you can get a pre-auth foer the surgery.
Doesn't guarantee you they will pay every last penny, but it will be a
covered procedure. You might get hit with UCR charges, but still way less
than paying for the whole thing. All of my providers did not have
contracts with BCBS and all I ended up paying, above my deductible and
copy, was $101 of my anesthesia bill, out of $26,000+ of charges.
<p>Regarless of what anyone told you over the phone have your surgeon
submit a pre-auth letter with the proper procedure code and a diagnosis
code of MO. Let then deny it in writing! Make sure to include a detailed
diet history, which can be put together by you, and have the surgeon
address your most serious co-morbs.
<p>If indeed there is a clear written exclusion then it's not worth
your time to fight with BCBS as they won't budge. Better plan on
self-paying then, which I stinks but sometimes it not worth fighting as you
won't win! Trust me I love to fight BCBS, and in all cases so far I have
won, but not with clear written exclusions in the picture.
— zoedogcbr
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