Help Needed...exclusions

Okay, I got a doctor, and am ready to go forward.  The billing lady called for coverage from my insurance and said that they had an exclusion and would not cover bariatric surgery....WELL DUH!!!!!!!!!  I had told them up front that there was an exclusion and I would be having my other docs and PCP writing a letter to state that  the surgery was "the only treatment" for my comorbidity(s) and that then they should cover it......( some info I found here on the boards).  They will not even make an appt for consultation until they get insurance verified.  SOooo....my question is.......What is my next step?  Do I rally the docs and send the letters to the ins co myself?  Do I go to the company HR with letters asking for exception to the exclusion???

Any help on this subject would be greatly appreciated as I am really bummed out right now.  I had an appt for Friday afternoon and now I cannot keep it.  It is like dangling a carrot in front of the horse and then taking it away.

Sigh,

Karen

I think you need to hire a lawyer, personally (with no guarantees).The letter from the PCP probably will not carry any weight.

An exclusion does not determine if something is medically neccessary or not.

It only states if it is covered or not.

Even if your doctor says it is medically neccessary, they can come back and say "maybe, but it's not included in the coverage contract."

Another route is to go to HR, and get an exception (only if it's a self-insured plan!), or write a letter asking they include coverage when they renew their contract. (I have a sample letter in my profile.)

I'm in the same boat.  My surgeon's office listed me as self pay so we could get the ball rolling.  I've been to the initial consultation with the surgeon, initial meeting with the nut, pre-op testing, and psych consult.  I have letters from my cardiologist/sleep doc and nephrologist that make it sound like I should have been dead and buried yesterday.  I'm still hoping my rheumatologist will write a letter (though I've about had it with his office staff) and my PCP is the last one I'm waiting on.  He wants to see me on Wednesday and he plans to check my cholesterol (hasn't been checked in over a year) before he writes his letter of medical necessity/medical clearance.  Once the surgeon's office has the PCP's letter, they will give me the packet of material to submit to my insurance (they refuse to do it since they know there is an exclusion).  I will submit all of the stuff with my well written letter of why I need the surgery and anticipate my denial.  Once I get a denial, I will hire an attorney.  That's how I'm handing the situation.

Also, after I get my denial, I have another letter that will be sent to the governor, my state representative, my HR department, state insurance commissioner, and a few other political people.  I work for the public schools and they keep complaining that Georgia keeps climbing in its obesity ranking yet THE STATE excludes WLS for their employees.  Something isn't right in Denmark!

Good luck!
Elli

I would love it if you would share your letters as I am trying to get an exclusion overturned and am just starting the fight. Any additional info is greatly appreciated.

Thanks,

Karen