Insurance Denied-Now what

daniels08
on 12/11/08 12:09 pm - Marion, IA

When I started this process back in May 2008, I was told from my insurance co. that surgery was covered if medically needed. My doctors and everyone involved stated via letters that surgery was medically neccessary. Now I have been denied and the insurance co. states that bariatric surgery isn't covered under the type of insurance that I have. I know I need to appeal, but what needs to go into an appeal letter? Does anyone know of sample letters that I could follow? Do I have all my doctors write a letter again to the insurance co? Please help.

Kristin B.
on 12/13/08 12:23 am - West Des Moines, IA
VSG on 05/17/08 with
If bariatric surgery is not a covered procedure under the insurance contract then an appeal will not do you any good- medical insurance policies can vary just as house and auto insurance policies can. If bariatric surgery was a covered benefit and you were denied- then you would have grounds for an appeal.

Just like some auto policies don't cover glass repair or roadside assistance some medical insurance policies don't offer bariatric surgery.

Many people have run into this issue- I personally decided on self pay but some change jobs or insurance companies if possible

It is a tough situation- I hope you find an answer that works for you



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Kari J.
on 12/17/08 7:24 am - Ankeny, IA
Getting insurance approval is usually the biggest roadblock to having surgery.  I was denied twice before I finally went to bat and fought and actually got them to change their requirements for approval.
What type of insurance do you have?  Who within the insurance company told you that WLS was covered? 
Companies often offer different types of insurance plans and sometimes you are under one that excludes coverage for WLS.  So if you called in to the insurance company they could have told you they cover it--but not known that you were under a plan that excludes it.  Insurance companies are messy business!  You need to get (in writing) your plans coverage and look closely.  It should tell you whether or not it covers the surgery and if it does, it should tell you what requirements you need to meet for approval.  Good luck!
Kari


Highest Wt 283
Wt at start of Pre-Op Diet 279
Surgery Day 268

"You have to take some chances, you have got to risk it all. You need to close your eyes and leap because it may be worth the fall." - author unknown

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