fed bcbs initial surgeon consult denied

Hi, Has anyone had this happen? My insurance covers both gastric bypass and lap band, so I took what I thought was the first logical step and made an appointment with a bariatric surgeon.  My BMI is 41 so I fit the weight definition without co morbities.  He gave me the list of things he needed such as PCP letter, stress test, psych evaluation.   I began the process of filling all these requirements and than I get a explanation of benefits telling me that the office consult was not covered.  They directed me the the general exclusions section  which says. they do not cover services, drugs, or supplies for the treatment of obesity, weight reduction, or dietary control, except for gastric restrictive procedures, gastric malabsorptive procedures, and combinations of restritctive and malabsorptive procedures.  What is that about?  How are you suppose to have  the procedure without actually having a visit with the surgeon? I'm hoping that this was an error and not the beginning of a huge battle, because right now I'm looking at a bill for $304.24 for consult never mind what all of the rest of the testing will cost..   Any suggestions?

My guess is that your insurance is like mine...they will cover morbid obesity 278.01 but they will not cover obesity 278.0 check with the surgeon's office and have them resubmit with the 278.01 dx code. (I also have BCBS and have had this same thing......they will pay for nothing coded 278.0 but will pay for 278.01).

Technically morbid obesity is defined as:

Morbid obesity
The condition of weighing two, three, or more times the ideal weight, so called because it is associated with many serious and life-threatening disorders.
278.01 is a specific code that can be used to specify a diagnosis

which having a BMI of >40 fits the two times the ideal weight so recoding should get them to pay. Be sure to notify your PCP of this when you are working on your 6 month supervised diet plan.

Good luck. You may want to call BCBS and ask them to send you the section on WLS, it is helpful to cross-reference the payable codes in the section with the codes the office will bill for.

Wow!  I have the Standard option on BCBS FEP myself.  I haven't gotten my EOB back from my consult, but I'll make a point of watching for this.  I know in the brochure it says specifically that they also cover pre-surgical testing and specifically mentions the psychological evaluation as well.  I'd say this has to be a mistake on the part of the coding or something.   I hope this gets sorted out for you soon! Kim :0)

This is almost like being in a three stooges show. I called bcbs and asked them why they didn't pay, they told me it wasn't coded properly, so I call the surgeons office and tell them that BCBS said it wasn't coded properly ( I was at work so I didn't have the codes the the other person was kind enough to post for me).  They tell me that it certainly was coded properly and that BCBS does this all the time.  They than asked me how does BCBS want it coded, I said I didn't know but I would call and find out and get right back to them.   So, I call BCBS again and get the same answer from a different rep,  I ask her well how do you want them to code it and get this!  SHE TELLS ME THAT SHES NOT ALLOWED TO TELL ME WHAT THE PROPER CODE SHOULD BE HA!  This is a 3 ring circus.   So I call the surgeon back and she laughs, she than told me that being I have a hiatal hernia that he is also going to repair that they will code it for this.   Can't wait to see what happens next.   On the up side, I passed all of my testing, psych evaluation, stress test, and all of the other blood work and such.   I actually a little worried because I only have one co-morbidity (gerd) otherwise they say I'm extremely healthy but my BMI is 41 so I shouldn't have a problem with approval.  It must be that 7 hours of walking I do everyday, if only it made me thin! Josie

I had the same thing happen (BCBS FEP).  They denied paying anything that was coded for obesity.   And I was also told they weren't allowed to tell me what code to use.  A girl I work for does insurance claims, and she told me to call the doctor's office and tell them to resubmit it as "hyperlipidemia," seeing as the office visit was for a consult because my labs were so awful (triglycerides 424), which is what sparked my interest in getting lap band.  

I also have BCBS FEP and the same problem with my pre-op lab work and psy. exam. This has since been corrected and paid for by the insurance company. Your problem is a coding error on your paperwork submitted by the doctor. When you get ready to have your lab work, see your primary and see nutritionist make sure that they code everything correctly.  BCBS FEP, basic will pay for the psy consultation and psy. test  This is the only problem that I have run into so far.