Any hope with an exclusion policy?

I'd love to hear from anyone that got approval even with an exclusion policy in their contract. -Cindy [email protected]

Cindy,I have an exclusion clause in my policy that specifically excludes WLS surgery. However, with a grievance letter (copied to the state board) I was approved in 3 weeks after receiving the first denial. Check out my profile, I posted the exact letter I used to get approved. I haven't had the surgery yet but at least I am approved. See, they may exclude this surgery thereby causing many folks to give up hope and not even try. However, the main purpose for medical insurance is to help you get well when you are ill, and more and more states are recognizing obesity as something that causes such significant other problems (hypertension, diabetes, etc) that NOT doing the surgery can be detrimental to one's health and are looking very closely at insurance co denials. Especially if they have EVER approved on before. Hope this helps. Roger.

Cindy, Just in case you couldnt find I'm copying my info here for you, it is interesting to note thatn when i received my approval letter they specifically stated that WLS is in the exclusion portion of my policy, I never read that or may have been discouraged from even trying, after I was approved I went and looked and sure enough it was there, excluded as all get out. : Persistence is key to success when dealing with HAP, or probably any HMO. My doctor submitted my referral to them and I waited a couple of weeks and checked and they said they never received anything. Submitted again and three weeks later received my rejection letter. Immediately appealed and gave them an additional 10 days beyond the normal 30 days to get information form my doctor. Three weeks later received approval. My advice is to persist and pu**** is really up to you to get this done. After all, it just makes sense for the insurer to deny and delay, after all, perhaps this will give you time to change your mind: Here is my exact appeal letter - feel free to use any part of this and good luck: HAP Attn. Associate Vice President, Client Services 2850 West Grand River Boulevard Detroit, MI. 48202 RE: HAP 1273200 Dear HAP, I am writing this as a formal grievance requesting appeal of your decision to reject my doctors (Dr. Mark Zawisa) request for bariatric surgery consult with Dr. Jeffrey Genaw as being "beyond the scope of my medical insurance". This surgery and the consultation requested is necessary for a number of reasons: 1) My weight is 345lbs and my height is 5'11" putting my BMI over 48. The National Institutes of Health (NIH) states that to be a candidate for weight loss surgery your BMI should be 40 or greater. Or you should have a BMI of 35-40 and have a co-morbid medical condition such as diabetes, heart disease or sleep apnea. You should also have tried other methods of weight loss. 2) I have sleep apnea which I am currently being treated for with a CPAP machine each night. 3) I have high blood pressure which I am currently taking Zestril. 4) I have tried for the last 15 years to lose weight with various methods, Weigh****chers, Atkins Diet, medical diets from doctors and many more too numerous to list with no lasting success. You are currently paying for the co-morbid conditions requiring treatment and I am very afraid of the future health care conditions which will result from these and others not yet surfaced (potential cardiovascular problems, joint problems etc). I know my insurance is there to prevent and assist with any life threatening situations and for me this is it. I at least want to have the consult with the bariatric surgeon to see if this is a potential treatment for me. Afterwards, if it is, then I would want the surgery covered as well. I realize you are expense conscious but can't you possibly see that my long term health care costs will far outweigh the cost of this surgery? I have been a HAP HMO patient for many years and expect to continue to keep this affiliation. Also, I have discovered that many other heath care insurers now treat this as a normal procedure for obesity and that HAP is one of the absolute worst for getting approvals. Why is that? I am beginning to think that perhaps more government attention needs to be focused on this issue for health insurers as many I have talked to say is the only way to get you to change your policy of Denial, appeal, denial, appeal, then finally relent. I know other HAP insured people have had the surgery approved and they all say it was tough working thorough the process with you and you make it difficult trying to discourage and causing many to lose hope and the will to push for the proper treatment. That's OK, lets just get it done, and tell me what I have to do next. Sincerely, Roger Lewis

Thank you so much Roger.... Before today, I was really planning on waiting till next January for open enrollement, but after reading that you got an approval, I actually have some hope. So it only took one appeal letter for them to approve you? That's wonderful!! Keep me updated.... BIG HUGS-Cindy

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Insurer Policy	United Healthcare (PPO)
Insurer Status	(09/05/02)
Surgery Type	Laparoscopic RNY
Pre-Op BMI	61.7
Comorbidities	Sleep apnea, arthritis, malaise, etc etc
Policy	Written exclusion policy
Comments	UHC has no choice in Maryland anymore as the state passed a mandate forcing health insurers in this state to cover obesity surgery. Without that mandate it would be nearly impossible to accompli**** seems.

   

Insurer Policy	United Healthcare
Insurer Status	(08/20/04)
Source	June Jones-williams
Insurer Policy	United Healthcare (Options)
Insurer Status	Approved after first letter (09/02/04)
Surgery Type	Open RNY - proximal
Weeks to approval	1
Pre-Op BMI	43.9
Policy	Don't know
Comments	It only took one week. Dolores at Doctor Vanguri's was wonderful. She got everything to right person the first time! If you are using a different Doctor, be sure to call 1-866-203-9168 extension 06123 and ask for your approval. When I called the main number on the back of my card, I was told that my insurance had an exclusion for this surgery. I informed them about the new mandate for Maryland and the person I spoke with put me on hold, checked it out and gave me the above phone number to check on my status (she said I was right about the mandate). I did not have to check, because the same day I got the number, I also got the approval letter. Good Luck!

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