Blood transfusions/products denied as a plan exclusion

Some responds here have been very helpful so hoping I can get some additional assistance and thanks in advance.

My employer recently switched to Accolade/BCBS this year (had no issues with Cigna last year). My wife needed blood transfusions due to a blood cancer and BCBS denied these transfusions as a plan exclusion. Due to the nature of the cancer she needed special blood products (billing code P9058) and specially Accolade mentioned blood derivatives are a plan exclusions. The EOB states “your benefit plan does not cover this service. Please refer to the exclusions section of your benefits booklet for specific details.” However when I look at the employer SPD (self funded plan) there are no clear exclusions I see. The plan mentions “coverage includes … blood transfusions” and the only exclusions are “fees associated with the collection or donation of blood or blood products” and “blood administration for the purpose of general improvement in physical condition.”

Is this particular code (P9058) considered a collection/donation fee? When I look at the code it seems this is associated with the blood product itself, not the collection/donation cost.

Any recommendations on what I can do or am I just SOL? Can I appeal or otherwise protest the situation to find a way to get coverage? Out of pocket cost would be around 4,500.

I contacted Accolade as well as my employers HR and it’s been a s***show of inconsistent information. At one point my employer indicated BCBS was just waiting to finalize pricing (about 2 months ago) and then I was blindsided with an update this week with a response this is an “excluded service.”

Thanks so much for any help or advice!

submitted by /u/StarFire82
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