Insurance Won't Cover Surgery

Hello all - my insurance (BC/BS) will not cover any of the of the cost of bariatric surgery, because the employer has elected to specifically exclude it from their policy.  I am morbidly obese, and suffer from several comorbidities...including diabetes, HBP, high cholesterol, and arthritis.  I would have the surgery tomorrow if that was an option...but unfortunately, I cannot afford the cost of private pay.  Does anyone know of ANY possible way to work this out so insurance would cover it?  I would be happy to write an appeal to someone...but as I haven't technically been "denied" really, I don't even know where to begin.  I'd welcome any suggestions or advice! 

If it is specifically excluded, you have no appeal rights. If self pay or changing jobs is not an option, the only thing I can think of is this http://www.wlsfa.org/

Self pay is quite a *****eaper out of country, so that might be an option. I had to wait four years for my surgery until I had insurance that would cover it. Sorry you are in this situation. Good luck.

Once in a blue moon a person will post that they've had luck making a case to their company's HR to get the bariatric surgery exclusion removed.  So that could be an avenue of approach.  

Get in touch with Walter Lindstrom's office. They helped me with my appeal and I won. Surgery was included, but I didn't meet their nutty requirements. On their site, they talk about ways you can appeal a complete exclusion. Kelley Lindstrom will spend all the time you need on the phone for an initial consult with you. From what I understand, there are provisions written into the Affordable Care Act that do open the door to successful appeals based on medical necessity. Lindstrom's office can help you sort this out.

Good luck,

Laurie

It is possible that your company has an Un-discussed fund that they set aside for 'medically necessary, excluded procedures'.

I would reach out to HR, privately,  and ask if there is ANY way that they can help you with an appeal to YOUR company, not to the insurance company.

Your company does not pay premiums....you can't appeal to BC/BS .... But I was self pay (5 years ago for the same reason) and a month later a co-worker with several co-morbidities got his VSG covered by our company due to their evaluation of his medical necessity.

It can't hurt to ask.

When I went to the initial class, the insurance department of my doctor's office said this is common. They also said there's a lot of times you can go to your HR department and talk to them to see if you can work out something for a special inclusion due to the fact you are costing the insurance company so much money with the comorbidities. They said it works more often than you think!

Good luck!

I second the recommendation to contact Lindstrom Appeal wlsappeals.com Walt is a great guy (I served on the OAC board with him and he's WLS 25 year post op too.) If there is a way to make it happen within your policy Walt will find it. Exclusions may only need verification of "medical necessity" and one of your comorbidites (diabetes perhaps) may qualify that. I wish I had known about him when I had my insurance issues. I self paid in Mexico. Medical tourism is not an option for everyone but it has been a wonderful experience for me (actually 3 wonderful experiences as I went back for post weight loss reconstructive surgery too.)

Best wishes!! It's worth all the hoops!

~Michelle "Shelly"

I appreciate everyone's advice!  I have talked to the HR department several times, and they flatly refuse to make any exceptions.  I even offered to pay the premium difference if they would look at the option of providing it as a benefit of my policy, and still nothing.  So, the HR route won't help. :(

I would be looking at self-pay options, too. Given all you've said about your health, and the fact that your BMI is 51, I suggest you contact the office of Dr. Ungson in Mexico. Last time I heard, his price for a complete DS (the form of WLS I strongly suggest might be best for you, given your BMI and your co-morbs) was around 16K, everything included. And by 'everything' I mean surgery and all associated costs, plus a two-week stay in his hospice.

It's cheaper than a new car, and will last a lifetime.

My insurance wouldn't cover the surgery of my choice, so I went outside the US for my DS. Home equity loan, and it was less than a used car. The absolute best thing I've spent money in my life.