EMPLOYER OPT OUT OF COVERAGE/INSURANCE DENIED/APPEAL

pertrea1
on 9/27/18 9:22 am

Good afternoon, I need help on what to do from here. PLEASE. I'm in the process of writing an appeal. My PCP deemed the surgery medical necessary do to my hypertention/cholesterol.

hollykim
on 9/27/18 10:07 am - Nashville, TN

Revision on 03/18/15

On September 27, 2018 at 4:22 PM Pacific Time, pertrea1 wrote:

Good afternoon, I need help on what to do from here. PLEASE. I'm in the process of writing an appeal. My PCP deemed the surgery medical necessary do to my hypertention/cholesterol.

if your employer "opts out" of buying coverage for weight loss surgery for its employees ,no letter of appeal or anything else will make the insurance company pay for it. Not even medical necessity.

The insurance company doesn't have to pay for a surgery that your employer hasn't bought the coverage for.

i suggest you look into self paying in the states or in Mexico,where many in this situation have gone,myself included.

artchikk
on 9/27/18 10:08 am

RNY on 02/12/18

I work in insurance pre-auth's and I can tell you that if your employer opted out of bariatric surgery coverage on your insurance plan, there is no amount of appealing it that will get it covered.
I am sorry to have to break the news to you, but they will just tell you it is not a covered benefit on your plan.

The best advice I could give you would be to either look into self-pay options, financing, or surgery in Mexico which can be significantly less than what you would pay in the US.
check the bariatric surgery in mexico forum and get some referrals or ask questions you may have there. LOTS of people do it, and it can even sometimes be more affordable for people who do have insurance that covers WLS because of high deductibles.

good luck and I hope that you find a way to get the surgery you desire!

Amber
RNY 2/12/18
5'4 1/2" tall, HW : 315 lbs, Surgery Wt: 297lbs.
M1: -17.5lbs M2: -11.5lbs M3: -12lbs M4: -13lbs M5: -13lbs M6: -13.5lbs M7: -12lbs M8: -14lbs M9: -10.5lbs M10: -7.75lbs M11: -5.25lbs M12: -4lbs M13: -3lbs M14: -7lbs M15: -2lbs M16: -1lb **made it to goal!**

CW 148

Gwen M.
on 9/27/18 10:17 am, edited 9/27/18 3:18 am

VSG on 03/13/14

Appealing to your employer's HR is the only appeal that might be useful in this situation.

VSG with Dr. Salameh - 3/13/2014
Diagnosed with Binge Eating Disorder and started Vyvanse - 7/22/2016
Reconstructive Surgeries with Dr. Michaels - 6/5/2017 (LBL & brachioplasty), 8/14/2017 (UBL & mastopexy), 11/6/2017 (medial leg lift)

Age 42 Height 5'4" HW 319 (1/3/2014) SW 293 (3/13/2014) CW 149 (7/16/2017)
Next Goal 145 - normal BMI | Total Weight Lost 170

TrendWeight | Food Blog (sort of functional) | Journal (down for maintenance)