How can I make Insurance cover surgery?

Regine · 03-15-2008, 07:31 PM

Hi
I am new to this and will just now start to gather info as much as I can. Thought I woulod start here.
I have 2 coverages. One is Premera Blue Cross and the other one through my employer Regence Blue Shield.
Before I put the war paint on and call them

, is it please possible to give me advice as to how you got them to pay your surgery?:confused2:

Your help, advive and guidance is greatly appreciated.

Savedbygrace · 03-15-2008, 09:52 PM

Your Regence BC is primary? ( because it's your employer) Do you have their website? If so, they should have medical policies on there that tell you exactly what you have to do to get it paid. That's assuming they DO cover LAP-BAND®. I'll see if I can search for both ins. companies websites and see what I can help you with. All insurances are different.

Regine · 03-15-2008, 10:02 PM

OMG Wendy I thank you so very much for your help and congrats to your approval. I hope i can say the same in a few weeks.

Savedbygrace · 03-15-2008, 10:04 PM

Regence's policy
Surgery for Morbid Obesity

Premea's policy
https://www.premera.com/stellent/gro...36918_6140.pdf

For some reason, I thought I read that you're from Washington... but I can't find what made me think that lol. Both websites have different states so they may have different policies. These are both for Washington. Let me know what state you're in and I'll see if they are different from these. Good luck!!

Savedbygrace · 03-15-2008, 10:06 PM

You're welcome. I battle insurance companies every day on the job so I try and do what I can to help anyone I can. They (insurances) can be a pain sometimes!!!

Regine · 03-15-2008, 10:12 PM

This is what i found:

Exclusions:

In addition to the exclusions listed in the “Benefit Exclusions and Limitations” section of
this Certificate of Coverage, Regence BlueShield will not cover the following:
• Travel expenses such as, but not limited to, transportation, meals, or lodging.
• Lap-band® procedures (adjustable gastric banding)
• Mini-gastric bypass
• Distal gastric bypass (very long limb gastric bypass)
• Biliopancreatic bypass with or without duodenal switch
• Roux-n-Y greater than 150 cm
• More than one bariatric surgery for you or your enrolled dependent while covered under this plan
or any other employee medical plan component of The Regence Group Health and Welfare Plan.
• Any bariatric surgery that has not been preauthorized.
• Any bariatric surgery not performed in a contracted bariatric surgery Center of Excellence.
• Weight loss reduction programs, diet programs, gym fees, and drugs for weight loss.

• Pre and post operative requirements

What insurance do you have and how did you it get approved?
Looks like insurnace companies won't help me and rather have me dead. I am so frustrated. What can I do?

Savedbygrace · 03-15-2008, 10:19 PM

Where did you find that? YOUR specific benefit booklet? Online? Is there a date on it?

It's very possible that Regence covers the surgery, but your plan may have exclusions. If that's the case, my advice would be to talk to your human resource contact about seeing what they (the company you work for) can do about getting that removed.
According to the policy I found, it says as of 1/07 the procedure is approved. About 1/3 down the page, it gives the criteria for coverage.

Regine · 03-16-2008, 01:53 PM

i found it online on their site.
I will talk to HR tomorrow. I have absolut no clue as to what to ask for. I am so blonde when it comes to insurances. it's pathetic already. Man, i haven't even started yet and I am about to give up already.
thanks so much wendy

snogirl · 03-19-2008, 12:15 PM

Regine, you need to look at the exclusions listed for YOUR specific plan.

I have premera blue cross and did NOT have any WLS exclusions in my plan, and my surgery was covered. However note that my employer offered two different plans through PBC- one had the exclusion, and the other didn't, so when choosing my plan, obviously I chose the one that didn't have the exclusion.

Employers are the ones who choose what they will cover and what they won't, not just the insurance companies. So before you get discouraged you need to get the right information. Also, you can always try to get approval because of medical necessity even if you have an exclusion.. it's worth a try.

figbart · 07-03-2008, 10:16 PM

Quote:

Originally Posted by snogirl

Regine, you need to look at the exclusions listed for YOUR specific plan.

I have premera blue cross and did NOT have any WLS exclusions in my plan, and my surgery was covered. However note that my employer offered two different plans through PBC- one had the exclusion, and the other didn't, so when choosing my plan, obviously I chose the one that didn't have the exclusion.

Employers are the ones who choose what they will cover and what they won't, not just the insurance companies. So before you get discouraged you need to get the right information. Also, you can always try to get approval because of medical necessity even if you have an exclusion.. it's worth a try.

Hi I am new and going in for my appointment next Wed for evaluation for surgery..............I have Premera Blue Cross Foundation WEA............as my primary and Uniform with my husband.........Do you know if they cover it? and did you have to do the 6 month diet thing?
Thx