How hard would it be to get past the following exclusion:

I have Regence Blue cross/Blue shield of Oregon and under exclusions it says: Services and Supplies not covered: >Services and supplies provided for obesity or weight reduction, including complications arising from such treatment. I have called the insurance company and the man I talked to said "Your coverage does not cover gastric bypass. I will send you out a denial letter because that would be the best place to start in order to appeal it and try to get it paid for." Does this sound hopeful at all? And just to add a little more info... I am 37 years old, my bmi is 64%. I have diabetes, high blood pressure, sleep apnea, underactive thyroid, depression and anxiety. I also have an enlarged heart and fatty liver. I have dieted my entire life! I have lost and gained so much weight in my life. Diets don't work. Period. I am afraid to even try to diet again because my last attempt, which was last year, I lost almost 70lbs but ended up gaining every ounce of it back plus 14 lbs! Each time I lose weight, I gain it back plus some. I am afraid of gaining so much weight that I can't walk! I have 2 children, ages 9 and 17, they need me. Any info would be most appreciated! (I was also considering possibly getting an attorney. Do you think this would increase my chances of having this surgery approved?) TIA!

Absolutely APPEAL!!! See my post to MissScorpiokutie right below this question. Most insurance companies deny the first request automatically. They are hoping you will stop asking. DON'T STOP!!!! Many people on this board have been approved after an appeal (or two, or three....). Best of luck to you also! Dawn

Definitely appeal! Have you considered looking into the Biliopancreatic Diversion w/ Duodenal Swith (commonly called the DS) surgery instead of the RNY? It is especially good for patients with high BMIs such as yours. If you haven't - check out the Duodenal Switch forum page from Obesity Help. With all of your comorbidities and your high BMI, I would think you would have a great chance at getting approval with an appeal. Is your PCP in support of you seeking weight loss surgery? If you do seek an attorney, I have seen several people post about winning appeals and listing their attorney's names. I can't remember them off hand but you should be able to get that information somewhere on this website. GOOD LUCK!

Appeal. It does matter though what state governs the plan or whether it's a self funded federally governed plan Gary Viscio www.obesitylawyers.com rny 7/1/03 -165

Hi Gary. Any luck with getting past exclusionary clauses with Aetna? I have a Type I diabetic 18 year old man who meets all criteria (including a very long history of dietary/diabetic education) for Aetna, however being denied due to exclusion. He is a very sick young man, already on Insulin pump at 18 years of age. Wondering if you have ever had success with Aetna (besides my mom of course...) before I steer him your way. Don't want to give any false hope. Any suggestions?