Introductory/Insurance/Inquiry Post

When I called my insurance company, they said no WLS. When I called the doctor's office to check my insurance for me, they said no WLS. But I DO IN FACT have WLS coverage when it is medically necessary. Do as Diana says and get a copy of your whole policy. My policy says WLS is not covered. Period. And then in the next paragraph there is a discussion of what medically necessary means... There is No EXCEPT or anything like that. I just had to read and re-read very carefully! I'm learning to take matters into my own hands. Get that policy and read every word. I was right and it took me six weeks to get an appointment for a DS but it's worth it!

I agree completely with the advice about reading your policy for yourself, rather than trusting the word of an insurance company flunkie, or even someone in HR. No one cares more about this than you.
     However, if it proves true that you have no coverage, and esp in your new policy will not have coverage, there is for a short time only another alternative to get the DS right here in the USA with a very reputable, experienced DS surgeon who needs to accumulate a certain number of cases in a limited time frame for his hospital to become a COE (center of excellence).
     I'll send you a pm with details.

Larra

  Thank you very much, everyone, for your words of encouragement!  I did find on my insurance web page the following:

Subject:	Surgery for Clinically Severe Obesity
Policy #:	SURG.00024	Current Effective Date:	07/13/2011
Status:	Revised	Last Review Date:	05/19/2011

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Description/Scope

Clinically severe obesity is a result of persistent and uncontrollable weight gain that constitutes a present or potential threat to life. There are a variety of surgical procedures intended for the treatment of clinically severe obesity. This document addresses those procedures.

Position Statement

Medically Necessary: 

Gastric bypass and gastric restrictive procedures with a Roux-en-Y procedure up to 150 cm, laparoscopic adjustable gastric banding (for example, the Lap-Band^® System or the REALIZE^™ Adjustable Gastric Band), vertical banded gastroplasty, biliopancreatic bypass with duodenal switch, and sleeve gastrectomy (open or laparoscopic) are considered medically necessary for the treatment of clinically severe obesity for selected adults (18 years and older) who meet ALL the following criteria:

1. BMI of 40 or greater, or BMI of 35 or greater with an obesity-related co-morbid condition including, but not limited to:
   • diabetes mellitus; or
   • cardiovascular disease; or
   • hypertension; or
   • life threatening cardio-pulmonary problems, (e.g., severe obstructive sleep apnea, Pickwickian syndrome, obesity related cardiomyopathy); AND
2. The individual must have actively participated in non-surgical methods of weight reduction; these efforts must be fully appraised by the physician requesting authorization for surgery; AND
3. The physician requesting authorization for the surgery must confirm the following:
   • The individual's psychiatric profile is such that the candidate is able to understand, tolerate and comply with all phases of care and is committed to long-term follow-up requirements; and
   • The candidate's post-operative expectations have been addressed; and
   • The individual has undergone a preoperative medical consultation and is felt to be an acceptable surgical candidate; and
   • The individual has undergone a preoperative mental health assessment and is felt to be an acceptable candidate; and
   • The individual has received a thorough explanation of the risks, benefits, and uncertainties of the procedure; and
   • The candidate's treatment plan includes pre- and post-operative dietary evaluations and nutritional counseling; and
   • The candidate's treatment plan includes counseling regarding exercise, psychological issues and the availability of supportive resources when needed.

But what was not clear was is if this was for my policy specifically or just for the company in general...

I'm going to attempt to call them tomorrow.  Today was a busy day at work and I didn't get a chance.

I'm continuing to research alternative options.  Dr.  Stewart certainly has a more attractive price!  Does anyone know if he does this laparoscopically or open?  Dr. Greenbaum looks quite qualified as well but his website doesn't say how much the DS is. 

OK, this looks to me like your INSURANCE COMPANY thinks the DS is covered for BMI >40 (!) and with minimally restrictive requirements like a pre-op diet at SOME TIME IN THE PAST - no time limit as to length of diet or when it was done; psych review, learning about the post-op life, etc.  Easy-peasy!

BUT - does this page from the website apply to YOUR plan?  You need to get the full plan document that applies to YOU from your HR department, NOW!!!  Because if you submit for approval before your insurance changes, the NEW company is likely to be obligated to pay for it, even if they remove WSL as a benefit!!

NOW DO WHAT YOU WERE TOLD TO DO, IMMEDIATELY!!!

 I'm going to call the insurance company directly tomorrow.  My HR dept consists of one person who, while focussed on the shift of policies, has their mind elsewhere.  I'm hoping they can email the document.

Unless there was a preamble somewhere before the part you quoted which said "this benefit only applies if your insurance plan includes a WLS rider" you may have benefits NOW that you are at risk of losing in a very short while when your plan changes.  So please understand my vehemence!

Would your insurance company LIE to you to tell you that WLS was not covered?  YOU BET YOUR ASS THEY WOULD!  Especially when they know that your employer is dumping them, and they are not going to get any benefit of your improved health, but will bear all the cost of your surgery at the very end of your contract with them.

 Diana,  Thank you very much for your insight.  I'm going to call them first thing this morning with this policy #, reference website and CPT codes for the DS to ask specifically if there is a rider involved.  I will let everyone know how it goes.  

Welcome, I'm glad you posted.
I agree with Diana, with a possible change in beneifts you need to get on this right now.  And get yourself to a surgical consult so they can submit for approval if you are covered.

Well.  I just got off the phone with the insurance company...

The dreaded words:  "Your policy does not cover weight loss surgery.  It was excluded by your employer." 

Well, I guess that's about as clear as it can get.  From what I've read there's no way around that, right? 

 I found that the document of benefit summary is online and this is directly from the 5.5 pages of "Expenses the HMO/HMO Consumer Choice Healthcare Plan does Not Cover (Exclusions)"


Obesity – Any services or supplies for the treatment of obesity, including but not limited to, weight reduction, medical care or Prescription Drugs, or dietary control (except as related to covered nutritional counseling) and listed under Covered Services. Nutritional supplements; services, supplies and/or nutritional sustenance products (food) related to enteral feeding except when it is the sole means of nutrition. Food supplements. Services for Inpatient treatment of bulimia, anorexia or other eating disorders which consist primarily of behavior modification, diet and weight monitoring and education. Any services or supplies that involve weight reduction as the main method of treatment, including medical, psychiatric care or counseling. Weight loss programs, nutritional supplements, appetite suppressants, and supplies of a similar nature. Excluded procedures include but are not limited to bariatric services, bariatric surgery (e. g., gastric bypass or vertically banded gastroplasty, liposuction,gastric balloons, jejunal bypasses, and wiring of the jaw).

Curiously, the "obesity" paragraph was the longest and most detailed of the "exclusion" bullets.  

I'm going to be interested to read over the new insurance policy details of benefits.