Insurance rejection and appeals

Has anyone had a first time rejection from your insurance company and then got approved on a appeal? My insurance does not cover bariatrics but my doctor is deeming my surgery medically necessary so she told me it would get approved. So frustrated right now. I have severe gerd and diverticulosis. 2 doctor referrals, ekg, upper GI, manoscopy all showing I have bad acid reflux. If anyone has gone through this any advice would be much appreciated!! I am trying to get my VSG revised to RNY

Lots of people are denied for various reasons, and appeal successfully.

EXCEPT:

If your policy explicitly states that it does not cover bariatric surgery, it's 99.9 percent sure you are out of luck. Whoever bought the policy saved some money because it excluded certain things, like bariatrics. There's really no way out, with that policy.

It's like buying homeowners insurance that covers fire, but specifically says it does not cover floods. You can pay extra for that, but if it is written as an exclusion, that's pretty much it.

You can look into changing policies to one that will cover it. or look into self-pay. I've seen many that go to Mexico for surgery for much less money than insurance copays cost locally.

Good luck. Don't give up.

That's what I kind of figured but my surgeon was insistent that because it's deemed medically necessary they would cover it as it is coded differently. Mexico it is. I have been before. Just wanted to be closer to home for my revision. Thank you!

my insurance excluded it also. I was submitted as medically necessary and was still denied.

That is Linda the point of having an exclusion. It is an iron clad way to get out of paying , medical necessity or not.

It's Jenny and again my doctor and insurance company both stated it can be approved when deemed medically necessary. They have gotten approvals in the past even with the exclusion. We actually had our VSG around the same time holly kim. I remember you from 2010, you went to ds right? Did you have to go back to Mexico for your revision?

hey, yes I did go back to me for my ds. I hope it works out as they say for you. If your employer self funds your policy, it might work that way. Hope so.

It's your employer that chooses a policy to exclude wls, so perhaps bringing the letter of medical necessity to them and sharing that you intend to go to Mexico because they don't support their employees health might increase your chances.

It's great that your doctor told you your surgery would get approved. Unfortunately, your doctor is NOT your insurance company. S/he probably doesn't know the particulars of your insurance situation, so I wouldn't take the doctor's word as law.

Call the insurance company, use the number on the back of your ID card. Do they have a blanket exclusion on bariatrics, even if medically necessary? If so, you're going to be out of luck on coverage.

I did contact my insurance company previously and they told me it is excluded but when surgeries are deemed medically necessary they can get approved. It goes on a case by case basis.

Sounds like you were misled by a likely inexperienced phone representative.