Question:
Has anyone dealt with exclusions from HMO BCBS

   — [Anonymous] (posted on December 13, 2001)

December 13, 2001
Yeah I have an exclusion for "weight control" from BC BS south caroling.. these ppl are so screwed up they dont even know where Im supposed to get approvial from cause I live in alabama!! They dont know their ass from their elbow!! LOL Good luck
   — Dina L.

December 15, 2001
Are you by chance covered by a policy through a union? I am finding out that the Unions have specifically excluded weightloss surgery of any kind for any reason. No appeals will be looked at or reconsidered according to BCBS. And your right about one thing, they don't know there ass for a hole in the ground. I've went through all the procedures and everything was just fine, I was waiting on a surgery date and then found all this out. To me it seems like a blatant discrimination considering no other procedures have been excluded, at least not from my policy. But, I have no clue what to do.
   — gracie B.

December 15, 2001
I have BCBS of Texas...they have an exclusion stating treatment, including surgery, for obesity is not covered...However, treatment for MORBID OBESITY is covered. There is a difference in the two....that's how I got BCBS to pay for my RNY.
   — nguerra

July 8, 2002
This is a self-funded plan offered to state of Texas employees w/the same exclusion you posted. I've been working w/the group at COMPASS, used to be IMAGES, and they've confirmed that the BCBS-TX exclusion isn't iron-clad because the medically necessary clause has worked, and they're working with me to get approval based on that. I know there are several who've tried to get past this based on a LOMN and were denied, but my case-worker lady seems confident based on the information provided by her contact at BCBSTX. See below: Dear Lynda, I spoke with Lettie at Blue Cross today and was told that they will consider this surgery if medically necessary, however as you have an HMO they will not allow you to go out of network. I noticed that you stated that you will roll over to PPO in September. I would suggest we wait until after September 1 to submit the letter of medical necessity for approval as they will certainly deny it due to being out of network. Please let me know how you would like to proceed and thanks for letting us know that they will consider this procedure. Up to now we have always been told that this was a "definite exclusion" on this policy even with medical necessity. Thanks and I look forward to hearing from you. Sheridan at Compass GOOD LUCK EVERYONE!! :)
   — Lynda L.

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