Insurance

Hi All, I was told by Dr. Tersigni's office that both of my insurances excluded WLS. I had talked to my insurance company and they have a clause under exclusions that says "Services and supplies for obesity except for morbid obesity". They basically told me that that meant that they would pay for Weight Loss Drugs. Well, yesterday I got the insurance statement for my consult visit and they paid 60% of it! I guess that he is not on their prefered providor list. I do not think that the doctor formally submitted a form for the surgery, they said that they don't if it is an exclusion. To me it doesn't make sense that if they aren't going to pay for WLS, why would they cover a visit with a surgeon? Basically my question is, how do I go about trying to submit it myself to the insurance? What all do I need to do? Do I just send a pre authorization form? I was basically just going to give up and try to find a new job, I have my application in at a company that I know covers WLS. I really am not sure of what to do. Thanks!

Hi Amy, Sorry to hear about the trouble you are having with your Ins. Your ins does'nt sound to hopeful unfortuantly. Sorry to say. But you can at least keep trying until you possiably get that other job. My first question to you is has your reg Doctor written a letter recommending that you need WLS? Also,have you already tried weight loss drugs prescribed by your Doctor? If you have tried them before (wt loss drugs) then have your Doctor write that in the letter of recommendation and have the Doctor send it to your Ins Co. See what the Ins says about that. my first step in getting approved for WLS was through my Doctor,we did blood work,sleep apnea test. I told her all the attemps at losing weight such as diets I had tried and gyms I joined and exercises I did,she ( doc) documented all of that and all my co-morbities,hypertension,hip and knee pain etc.. My BMI was ^. My Insurance wanted to know if I had tried Merdia (wt loss drug) or any other drugs and my Doctor wrote in her letter of recommendation that I could never try any of the weight loss drugs because I had high blood pressure. So,get together with your doc and go over your health and family hx everything (if you have'nt already) and see what you can come up with. Maybe your Doctor's letter could open the door for you.?? Its worth a try.. I wish you luck. Jeanne

Hi Amy, I have to tell you that Providenece did the same thing to me. They paid for the consult, meeting with the dietician, and pshy. evals, and blood work. When it call came down to it, they denied the surgery because the surgery was not a covered benefit. Are you morbdily obese? If so, the exclusion may not apply to you. I ended up switching to Kaiser through my work. I fought Providence on a 3 level appeal and to the insurance comission abratration(sp?). They had an ironclad exclusion. BUT it would not hurt to try and submit to your insurance. If your surgeon is not willing to submit and try to help you, I would look for a different surgeon. You are going to need all the support you can get, starting with the person who will messing with your innards Best of Luck to you, Sarah G. 2/16/04 -127