anyone appealed an EXCLUSION and gotten approval

If any of you have appealed an exclusion I would like to hear your story.  I hope some of  you won!

I was told insurance would cover and now they are saying it is excluded.  I need tips for filing my appeal.

THANKS!

I have Anthem Blue Cross that is self funded by my husband's employeer.

I was approved, received an authorization number and approval letter, and then denied.  At one point in the process I called to check on the status of my medical necessity approval and the operator that answered told me I did not have coverage for the procedure.  I told her I and the doctor's office along with the psychologist that did my psych eval had all talked to different people and all said I have coverage.  The lady read further and then said the policy was confusing as in 2 places it says it is covered and in 1 places it says it is excluded.  She sent me a copy of what she was reading.  We do not have books of benefits so I had nothing to go by other than what the member services line told me and what I could see on "my Anthem" website.  It shows surgery covered at 80% if a participating provider and 60% if not a participating provider.  No specific surgeries were listed and there is nothing listed under exclusions.     

I did get a denial letter.  It is on Anthem letterhead and signed by a doctor.  It does not have the policy number on it.  It states that the approval letter confirmed medical necessity but that their "records indicate that gastric bypass surgery is not a covered benefit."

I am planning to have a lap DS.

Any advice you can give is GREATLY appreciated!!!

Insurance companies are required to make their policies "clear and non-ambiguous" to the average person. If they have conflicting info on their information you could easily win an appeal. I am appealing my BCBS tn exclusion using the Lindstroms' at WWW.obesitylaw.com. They will work with you on a payment plan to cover their fee which is very reasonable. Good luck!
Holly

I am not sure from your post if you are saying the Insurance Company has the exclusion or the plan your employer purchased from the company is the one with the exclusion.
For example I work for County Government and our coverage is with Cigna. Now Cigna itself does not exlcude weight loss surgery however the policy my company has with Cigna does.
It may help to know who your "fight" is with. If the issue is your employer's plan I am not sure an appeal to the insurance company will be of any use. If the issue is with the employer's plan your "fight" is with them and not the insurance company.

The exclusion is with the employeer.  But the insurance company they hire is the one that for months told me I do have the coverage and even had me do dietician consult, psych eval and appt w/ surgeon to approve as medically necessary and now they say it is not approved...

I am soooooooooooooooo frustrated!!!

Again the issue appears to be with your employer though it does appear the insurance company gave you bad information it appears they were basing it on what the insurance covers rather than what plan your employer bought from them. I understand you being frustrated and it appears your fight is with the employer still.

Have been o the phone with UHC and had  a meeting with my employer.  UHC says that I can appeal the exclusion and HR states that if a rider is obtained that it must be for all employees not on an individual basis.   I live in Md and there is a statute on the books that states all group health insurance must provide coverage for treatment of morbid obesity.
Between talking with UHC rep and my employer  UHC says that
the Medical director will make the final call but will be in conctact with my employer.  So who knows what will happen.

we will see.

If any one out there has any legal advise that will help dispurse this cloud it would be greatly appreciated.