Help, is there hope for me

I have been batteling weight loss all my life, I started my surgery journey a few years ago, I went through all the requirements of a surgeon and was denied, I switched my insurance to my husbands and was approved the same week he lost his job, so as you guessed no surgery. My insurance at work changed so I started my journey again with a new doctor and many more test requirements, dietician, shrink, sleep study, upper & lower GI, ultrasounds, x-rays, blood tests......and whatever else was on the list.  After all of the tests that my insurance paid for the letter went out and they denied me saying that my insurance does not cover weight loss surgery.  I appealed the letter and was denied again with the same response.  My question is do I continue to appeal?  Is there a way to get this approved.  The letter states that I could request a legal hearing but will it work or should I just give up and stop all the heart ache of being denied?  I'm not sure if anyone out there has actually gone so far has to seek legal action and have the surgery done in the end or if it is just alot of hoops for nothing.

First of all, take a deep breath and try to calm down. Believe me ,I know how you feel, I fought my exclusion for a long time. Second--where did you get the information on which tests you needed for approval? Did you call the insurance company or get the info off the web?  If you got it directly from a person at your insurance company, I hope you got their name and reference number of the call. If you can get them to verbally tell you that you have weight loss (bariatric) surgery coverage, you might have a case.  If you just got the generic info off the web, you did not get specifics on your policy. Your employer can choose if it's covered or not. For example, you can got to united health care's website and find the rules to get approved, but all of their policies do not cover it. Insurances are funny, they cover the testing but not the surgery, it's weird. My insurance is like that, so don't assume you have coverage because they paid for the pre-testing. The first call you should make is to your insurer, benefits and elegibility. Ask if bariatric surgery, CPT code 43644, is a covered expense. That is the code for RNY, but if it's covered, you know WLS is covered (in case you are seeking DS or band). If it is covered, you need to go back to your denial letter and re-read it. Denial letters are funny too. Does it say you have an exclusion or that it is not considered medically necessary. Insurers deem a procedure medically necessary when it meets all of their criteria, it something is missing, they will tell you it is not medically necessary. Obviously, I do not know your entire situation, but I do this for  living now for a bariatric surgeon. I have found and won several appeals for people who thought they had no chance, usually it just comes down to missing information. Something like a letter form a PCP, or the diet is not 180 days long, etc. Sometimes I have to read a denial 4 times to find out what they are getting at. Then, if you truly are excluded, appealing really will not help you. It is the law they tell you that you can appeal. Of course you can, and of course they will hear your case and say no, sorry, it's not covered. If it's an exclusion, stop wasting yout time and focus that energy on something else. Figure out a way to finance it. I had to, it was hard, but worth it. I wish you the best of luck! Bonnie

Thank you Bonnie for your reply.  All the testing I had done was through the bariatric surgeon and the insurance company paid for all the tests, they were his requirements.  My policy says that it is an exclusion which leads me to believe that they will never cover it , no matter how many times I appeal it.  I don't see me being able to finance it either, we live paycheck to paycheck and just lost our house to foreclosure so we are barely making ends meet at this point.  My husband doesn't have insurance where he works so that isn't an option either.  If you can think of anything else that would help please let me know.   Doreen

If your finances are that bad off, try medicare/medicaid for insurance. You might qualify for medicaid, some states guidelines are pretty easy to qualify. Don't be too proud, just apply.