Question:
Will Anthem BC/BS PPO insurance approve me?
I have a BMI of 49, there are 14 health problems caused by my weight and I can list 7 diets I have tried in the past that I can remember but only one was Doctor ordered. Does anyone think I will have problems? — Brenda T. (posted on February 28, 2002)
February 28, 2002
Well my first prediction is that they will deny you because you don't have
12 months of Dr. Monitored weight loss. They pull that with everyhody
including me.
Then have you Dr. write a letter that you have "serious life
threatening health problems" and that Bariatric Surgery in your case
is "Medically Necessary" and that he/she "doesn't recommend
12 months of dieting" and that they should approve your surgery ASAP.
Then write in your appeal letter (assuming that they will deny you the
first time around) that you meet all of the criteria set forth by both the
National Institutes of Health (NIH) and ASBS for bariatric surgery and that
12 months Dr. monitered diet is not generally accepted Medical practise and
therefore "an illegal protocal that they are using to arbitrarily deny
benefits for a medically necessary surgery." List out all of your
health problems and diet attempts. If they still deny you after that, which
they probably will, hire Walter Lindstrom (www.obestitylaw.com) as your
lawyer to file your appeal. He is very familiar with the crap that Anthem
BC/BS pulls and for $350 will likely get you approved. It was well worth
ever cent and after dealing with Anthem's runaround & crap for nearly
5-6 months, they approved me within 3 days of getting the appeal letter
from Walter. Any questions feel free to email me (however I am having
surgery on Mar 4 so it might be a while before I can get back to you.)
— Dell H.
February 28, 2002
I, too, have Anthem BCBS, but in Nevada. I was approved within a week.
While I did not have any truly "supervised" diets (my policy
requested 5 years worth), my weight was discussed at EVERY doctor's
appointment I had for more than that 5 years. I wrote a two-page history
of my life discussing how weight gain affected me, the discussions I had
with my doctors, the medications I was given to lose weight (even tho I
never went back for weigh-ins), etc. Evidently it worked! Like I said, I
was approved in one week. I am now 6 mos. post op and down 96 pounds.
Email me if you would like a copy of what I submitted.
— Pamela F.
February 28, 2002
Contrary to the previous two posters, the real answer is 'it depends'.
BC/BS is not the same insurance nationwide. In fact, most insurance
companies can differ from one state to the next. What's covered in one
state might not be in another. It's also possible that one company has
'customized' a BC/BS policy to exclude or include the surgery. The only
way to know for sure is to get a copy of the policy and read it. You
should probably start with the 'exclusions' part to see if it lists weight
loss surgery as being excluded. You can get a copy of the policy from your
human resources department. Don't believe anything your insurance company
tells you over the phone. ALWAYS get anything they say in writing.
— garw
February 28, 2002
Have to add that my BC/BS policy (in Colorado) requires 3 years of
physician supervised weight loss attempts. Notice it does not say diets,
but weight loss attempts. So now you have 3 different things, but from
people in 3 different states. Illustrates exactly what I just said.
— garw
February 28, 2002
Hey it's me again, my policy states in exclusions...
We do not provide benefits for survices supplies or charges;
Related to weight loss or treatment of obesity; except for surgical
treatment of morbid obesity.
— Brenda T.
February 28, 2002
Brenda, its me Dell again. That is exactly what my policy says too. Anthem
is one of the worst for getting approved, just read the insurer pages. Good
luck, and don't give up.
— Dell H.
February 28, 2002
i also have anthem bc/bs ppo but i am on the federal employee plan. the
only requirement for surgery in this policy is weighing 100 or more pounds
than ur ideal weight. i was approved in less than 48 hours.
— sheryl titone
February 28, 2002
Expect to be denied the first time and make sure you appeal.
I sent them a notorized statement from a friend who attended weight
watchers with me and they accepted that. I did go to a weight loss clinic
for a few months and the doctor had indicated in the records I was in WW.
Anthem denied my appeal saying my condition was not life threatening when
the first denial said not medically neccessary (due to not enough diet
history) my Dr said I should contact the attorney generals office since
they changed the criteria. I told Anthem appeals this and was approved
within hours. They said they reviewed the wrong Anthem policy. Good Luck.
— Candace F.
February 28, 2002
I have Anthem BC/BS of New Hampshire (don't know if that makes a
difference- I'm not very familiar with insurance technicalities) and I was
approved in less than a week over the holidays. I made sure that ALL my
paperwork went in at once, nothing missing and called the person every
other day. I think hearing a REAL voice on the other end of the phone
really helped. For the record- I am 21, only have one real co-morbid (but
the potential for many others), and a BMI of 42. Seven weeks out and down
30ish pounds. I hope you are approved. Good Luck!
— Angela B.
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