UHC Help or advice Needed They say it is excluded in Oregon

Hello there, So today I started two additional medications and now up to 8. This is for blood pressure, diabetes and not sure what else they are trying to control except for these two things.

I have the support of my regular doctor. I went to see a cardiologist to make sure I was healthy enough for the surgery and that my heart was in good shape. This doctor is also a  true believe and feels I am an excellent candidate. We contacted OWLLS and were told that the insurance will not pay for it. I do have an exclusion for weight loss surgery. To get around this I was told to have everyone go in with angles of all the needs to be done to remedy what is wrong.

I have never gotten a letter from anyone saying NO. I only get this over the phone. How does a person get past the main people answering phones? Get someone to look at all the records?

 

Anyone in Oregon know any way to get around this or some advice?

Thank you,

Dean

 

Have you hooked up with a surgeon yet?  They usually have an insurance coordinator who knows all the ins and outs, and they will submit the paperwork to insurance for you.  Once this is done, if it is denied, it will be denied in writing - then you will know the reasons why, and you can appeal.

Alternatively, if you don't have a surgeon yet, I would gather all your letters from your doctors, your medical records showing your BMI for the last 2 years and that your weight is the cause of your diabetes and high blood pressure, and a letter from your PCP or other doctor stating that the surgery is medically necessary to treat your diabetes and high blood pressure.  Then, send it all in (make copies!) to your insurance company.  They will write back with either an approval or denial, which you can appeal if necessary.

Good luck!

Thank you for the reply.

The surgeon is a good question. I have been in contact with Oregon Weight Loss and the insurance coordinator took all my information and is the first one that said the insurance company will not pay for any of it, even if it is medically necessary.  They wouldn't even see me unless it was a private pay basis.

My regular doctor had mentioned a few times about sending me to a cardiologist. I then said I wanted to know how my heart was as well. So he referred me to one. They did an ultrasound and a stress test. The Cardiologist said my heart is in great shape and that he feels the surgery would be a benefit to me and that I was a perfect candidate. He then wrote a letter stating all the things that are wrong and how much this would benefit my health.  I don't think this information ever got past the insurance coordinator at Oregon Weight Loss. I did talk with the insurance company and it doesn't sound like it would have made any difference.

I had heard there was a way around this if it was a medical need and not just weight loss surgery. :-(

Thank you again for responding and congrats on your surgery.  I am sure it said you had it last month. How are you doing and would you do it again?

 

I think it is really dependent upon your policy.  You can certainly try to get around it by going after a "medical necessity" argument, but they might come out and say that it is excluded, for all reasons.  If that is the case, then you are out of luck insurance-wise and will have to pursue a cash-pay basis.  You might have less expensive alternatives, however, if you pursue Mexico or other overseas alternates.  Of course, you always have the right to consult with an attorney who specializes in health care law from the patient view-point - they might be able to help you with appeals.

I did have my surgery last month - 12/27.  I must say, I almost feel like I haven't had it at all - except that I've seen the pictures and I am never hungry.  I went back to work after a week and feel great (tired, but great!).  I would do it again in a heartbeat, and wish I had done it 9 years ago when I was first looking into it.

Good luck!

There was an exclusion on my policy too and after spending $800.00 on a Wls advocate it was still an exclusion and I sell paid in mx. Save that money for self paying. There is no way around it. Because your employer didn't buy the rider for Wls so the ins isn't going to pay for something your company hasn't bought,right?
Gl

If it is excluded, they really mean it.  WLS benefits are an additional premium for your employer.  If that premium (rider) is not paid, they won't pay for your surgery.

MX can be a great option for self pay if you do your research.