Blue Cross PPO Coverage - ThinnerTimes

brookscn · 12-28-2005, 09:34 PM

I went to the support group/nutrition seminar tonight at Dr. C's office....Kelly mentioned that Blue Cross PPO might NOT be covering WLS surgery in 2006. Has anyone else heard this, or are you in process and being kicked back by Blue Cross?

I have Blue Cross Premium PPO (and it ain't cheap). In looking over my spankin'-new 2006 Medical Plan guide from my company, it clearly states in the exclusions that weight loss will not be covered UNLESS it is surgery to cure MO.

Am I being paranoid for nothing? I know there's a bunch of us out there in process with Blue Cross PPO.

Thanks! I know we have a lot of insurance afficionados on the forum!
Carolyn

YolandaG · 12-30-2005, 09:52 PM

I'm in the same boat that you girl and I'm have more weight over me than you.

I have PPO bc and they did not pay for this surgery. I put my appeal too, but they said (people who made the appeal) there are few, very few possibilities to get that surgery. They said that I need to be prepared for
a "NO".
Good luck in you case.

coptergirl · 12-30-2005, 10:07 PM

If the exclusion stated weight loss except for surgery to cure MO, then you should be covered if your letter states your weight, BMI, comorbidities, and other problems or issues you have due to being MO...you have a pretty clear cut case,my friend

LizardQueen · 12-31-2005, 06:00 AM

That is better than what my new ins book said. At least there is a maybe in there. Mine states that-Gastric bypass and gastric banding are exclusions to the policy even if these procedures are considered a medical necessity. Keep up the good fight!

coptergirl · 12-31-2005, 10:51 AM

Whatever the case may be, be your own advocate, gather all of your documentation, and fight fight fight! It is worth it!

kennieinVA · 12-31-2005, 03:22 PM

I have Federal Employee Program BCBS and have not heard of anything and I just got our new book in the mail about our benefits. It is a Standard PPO Family Plan, so I am not so sure how that works. Good luck with them honey!

RAY W · 12-31-2005, 04:57 PM

i work for union pacific rail road my company offers 2 policies blue cross and united health care dr wittgrove had me change to united cause he heard the same thing he said they were putting a freeze on surgeries do to restructuring and they were going to re-evaluate the medical necessity of rny. its all about there bottom line not about us even though we pay the premiums and thats SAD BUT TRUE

exit88 · 01-02-2006, 12:12 AM

I had Gastric Bypass November 9 in the California Blue Cross PPO. However, so far they have refused to pay the hospital bill. We shall see what happens.

Gina · 01-02-2006, 05:05 AM

Quote:

Originally Posted by kennieinVA

I have Federal Employee Program BCBS and have not heard of anything and I just got our new book in the mail about our benefits. It is a Standard PPO Family Plan, so I am not so sure how that works. Good luck with them honey!

I have this as well and I had NO problems at all. In fact they do not even pre- approve, they have guildlines and if you fit them they pay. I think total I was out 1500. 00 or so and 300.00 of it was the pschye eval because I had not filled all of my deductible. I am not sure if the Federal Employee is different or not but they do seperate us with the number. R ... whatever.

YolandaG · 01-03-2006, 05:10 PM

I think every insurance is differene from each other even it they look alike. Blue Cross may be the medical service but who pays the bills may be a differente one. The problem is the contract that everysingle company makes with insurance agents about what could be covered or not. Of course, we and they are talking about "money " how expense is the coverage and what coverge is inside the "frame". PPO for most of as is called for a employee "self-insurance, and there is no laws that obligate them to cover anything even if these procedures are considered a medical necessity.
(this means they have their ass well covered). My insurance for example PPO, has exclusions but not exceptions. They have clearly stlablished they will not pay for any any ws surgery. They also are not offering any other plan inside of usa but in Mexico and yea this is HMO. With this insurance (hmo) there is a state law that obligate them to pay if this is a necessery. I think you are going to see prety soon this kind of insurace PPO around here in CA. It is the most "convenient" for companies.
Can you tell me what is MO?
Thanks