Denied by Exclusion

Just curious. I let the Dr. call and my insurance said np, now as I read the exclusions, I see it is specifically excluded. I have talked to my company, but they tell me they cannot change it and the insurance says the company must. We are self funded. It is Great West of La. My question is this, I have Sleep Apnea. I have to wear a Bi-pap. Does having the surgery for this reason get around the no weight loss surgery?  Thanks, Michael

I too have sleep apnea, and I have to sleep with a CPAP machine and and oxygen machine.  My insurance has an exclusion about weight loss surgery.  I appealed, and was denied because of the exclusion.  Even with my co-morbidities, it was denied.  I don't think you can get around it if there is an exclusion. 

You're correct to think that, but it doesn't work that way.  It should, but it doesn't.   The problem is that when your surgeon puts in the codes for your co-morbidities, like sleep apnea, and then puts in the code for the surgery, they red flag it, and stop it.  The surgery should be done to help diabetes, apnea etc... as a primary reason in some cases but right now it doesn't work that way. It should be changed, I agree with you. Self funded exclusions are very tough.  Don't give up.  Stay at them.  Also, talk with your employer to see if they'll change the plan at all, even if they do it when the policy renews.

I work for GW and if it's an exclusion there is no way around it.  Your employer would have to take out that exclusion and it's really expesive and doubtful.  GW just administers the policy for  your employer.

I have talked to my company. Of course they are not very understanding.   I'll stay at them. I guess my greatest upset is that I let my hopes get up prior to this.

I too have Great West with "the exclusion". I need a revision as I have a leak. I have acid reflux, high blood pressure, 3 herniated disks, sleep apnea, and other various comorbidities. I had all the required tests and was waiting on the insurance reply before the doctor would set a surgery date. The insurance said NO WAY even after all the doctor visits and testing.