A question

I checked my mail this morning and got a letter from my insurance. It states that they won't make a predetermination because of the wls exclusion, but it also states that my plan does not require prior approval of benefits for the requested services and that it is "not a denial of benefits". It says that if i decide to continue with the services and a claim is sent to them, they will determine eligibility for benefits at that time, based on the provisions of my plan and guidelines for coverage. If they then determine that the services were medically necessary and were covered, they will provide benefits. It also goes on to state that if I disagree with the predetermination that I can request a review by the "Grievance Review Committee". The girl who handles insurance is gone on vacation at the Missouri Bariatric Svcs, so I guess I am left in the dar****il monday. My question is........what does this sound like to anyone else? Is there a possibility of the insurance covering? Or am I doomed? Thanks for any help Sheila

it sounds like your doctor and surgeon need to write really good notes and letters to them to include with the bill. but that they will pay if it is considered to be the thing that will make you healthy. Now if the Hospital and doctor are willing to do the surgery without a guarentee is another matter. They may want it paid up front and you get your money from the insurance company. I dont know. Talk to the girl in the girl in the insuance office of the surgeons office she can tell you more im sure. Jan

Thanks Jan. hugz

It sounds like you just have to prove to the insurance that wls is medically necessary because of your co morbidities. The docs can help with that but you will have to check with them, sometimes they wont do surgery without prior approval, but they may be familiar with your insurance company and know how to deal with them. The door is not closed but it is not wide open either. You do have a good chance you may want to contact obesity lawyers and have them look at the letter they know the wording and insurance companies pretty well and might help.

Hi Sheila. You must have gotten the carbon copy to my first letter! Well, after testing and testing AND testing some more...my surgery was completed 7/25. However, it has yet to be determined if this insurance (primary Blues plan) will pay. My secondary insurance is picking up the cost. I will keep the EOB's and post what if any benefits were paid. In the mean time, pick up the book, Gastric Bypass for Dummies. It gives some insightful tips on handling insurance, and has been a great source of information for me. My program was not able to be an advocate due to the number of denials for surgery, so be prepared that the doc's office may or may not be able to help you. Wish I had better news for you.

The key phrase in their letter is "WLS exclusion." A lot of insurance companies have now decided that precertification is costing a lot of money and it's just cheaper to ha**** all out after surgery is done. The surgeon who did my myomectomy yesterday is the one who told me this (and he only told me this because he was so impressed with my company's quick response to precert my surgery). My guess is that there will be a lot of people out there having surgery and then finding out that it won't be covered. The problem in your situation appears to be that you have an exclusion when it comes to bariatric surgery. Does your policy say "NO" or does it say "Based on medical necessity?" Mine said medical neccessity, and we had no trouble proving that. But if it's an outright "No way," you're pretty limited. The only thing you can do is get on the phone with people and ask about your SPECIFIC policy. Get it in writing, if you can (for some reason, my company won't give out copies of the policy). Good luck! Pamela

Hi, Sheila: I attended Dr. Hornbostel's seminar Tuesday night. He mentioned some attorney out in CA who specifically works on getting bariatric surgery approved thru your insurance company. I don't remember his name, however, the website is www.obesitylaw.com. I would suggest you call and/or email them and ask them if they would be willing to help you. I remember Dr. Hornbostel said it cost anywhere from $500 to $700 for their services. Might be money well spent. Debbie