Question:
Please help me decipher this HMO exclusion
I have Blue Cross California Care,an HMO.The exclusion reads:"Obesity--Services primarily for weight reduction or treatment of obesity. This exclusion will not apply to treatment of morbid obesity as determined by BC HMO or the member's medical group if the medical group authorizes the treatment in advance as medically necessary & appropriate." Without the words "surgical treatment", does this mean wls is not covered? My BMI is 45 & I have some co-morbids. The word "treatment" is quite broad. Any interpretations would be helpful. Thank you;) — [Anonymous] (posted on February 23, 2002)
February 22, 2002
Hi... I think you are probably OK! The key words are: This exclusion will
not apply to treatment of morbid obesity as determined by BC HMO or the
member's medical group if the medical group authorizes the treatment in
advance as medically necessary & appropriate. NIH standards (National
Inst. of Health) give a BMI of about 39 with comorbidities. When paperwork
goes in make sure your Dr. sends medical history, letter of medical
necessity and info on all of your comorbidities. I think so far it looks
good for you! Obesity is overweight; Morbid obesity is more than 100#
overweight with underlying health problems. Good luck to you.
— AJC750
February 22, 2002
Best bet is to call the ins. people!!
— Heather H.
February 22, 2002
sounds like it would be a covered service to me. It doesn't sound like it
excludes surgical treatment for morbid obesity. Good luck.
— Dawn H.
February 23, 2002
I think you're fine. I definitely read it that they will cover the surgery
for morbid obesity. My insurance policy has similar wording, but they do
pay for the surgery.
— garw
March 1, 2002
I'm an insurance agent and my interpretation of this is that if your
primary care giver or the person he referred you to says that you fit the
criteria of morbid obesity and is define d as medically necessary. If you
meet that criteria you should be fine. My best suggestion is to call ins.
co. and talk to a rep. they should be help[ful in telling you what you need
to do to get it approved. Contrary to many peoples thoughts the ins. co.
are not out to get you. They pay for the benefits they provide. Many people
tell you what their ins. covers, but they don't tell you what they pay for
those benefits. Good Luck Dave!
— David R.
Click Here to Return