Has anyone successfully reversed denial based on exclusion?

I would be delighted to hear from anyone who has successfully appealled a denial based on an exclusion. I was turned down because of an exclusion for "Services or supplies related to obesity, including surgical or other treatment of morbid obesity." I can argue diabetes, sleep apnea, congestive heart failure, asthma, etc.--there is no shortage of comorbidities. These are all conditions that are currently being covered, so it makes absolutely no sense that they will not pay for the surgery to correct these problems. In the long run, they will come out better financially, but the exclusion says "no, can't do it." If anyone has successfully fought this battle, please give me some hints on how you argued it. thanks!!!! Kay R.

I have heard that it CAN be done. I am in the process of gathering together my appeal now. Soooooooo...I can't tall you that I have been sucessful, but I hope to be able to say so soon. Just wanted you to know that you are not alone! Dawn

Thanks for your response. Good luck to us both. Do you have any SPECIFIC TACTICS in mind? My best thought to date is to emphasize the semantics game--obesity is excluded, but this is not surgery to treat obesity, it's a surgery to treat the comorbidities. Can you offer any tactical suggestions?

The way your exclusion reads, by including surgery in the wording, will be VERY tough. But yes, you have to convince them that the surgery is NOT for a diagnosis of obesity, but all of the various comorbidities. You may have to speak with your doctor about how your case is coded. If the diagnosis code is for obesity, see if he/she is able to change the diagnosis code to the most severe of the comorbidities. My exclusion does not mention surgery, just "sevices and treatment" so that is my first point in my appeal. Also, look at the "Insurers" part of this board to see if others with your insurance company have been approved. Try to cantact them if possible and see how they did it. (Although I have not had a lot of luck contacting people directly through the "email me" links.) Even if you can not contact them, if you can see that your insurance company HAS approved this surgery before, you can use that as a fighting point also. In the end, you can contact the insurance reveiw board for your state and argue to them that the surgery is NOT for obesity, but for the other life-threatening conditions that you have. Good luck to you also, I will say a little prayer for you! Dawn

Hi Kay! I am responding because my insurance company (Blue Cross/Blue Shield of Tennessee, PPO) has the same exact exclusion!!! Is this also your insurance company? I have not yet applied for approval but I go next week to a WLS seminar. I am very nervous and worried that I will be denied and I desparately need to have this surgery. I called my insurance co. and they said there was no way around this exclusion (of course they would say that!) I called my employer's benefits coordinator and she said she was uncomfortable talking to me about this situation (go figure?!?) and referred me to the insurance broker they used to purchase the policy and said that she could help me because she herself had had WLS! I called her and she said that she also had BCBS of TN and was approved for WLS due to it being considered a "medical necessity" and she said she had no problems at all being approved and that it only took a couple of weeks!!! I asked her if my employer needed to purchase a separate rider to override the exclusion and she said there was no rider that this was a standard exclusion on all policies now and that the way to get approved was to attend a WLS seminar and have the surgeon's office submit paperwork (letter stating medical necessity, my situation and co-morbidities, etc.) and stated that she didn't think I'd have a problem. So, now I am wondering if this is just a little game the insurance companies are playing with us to hopefully make us go away with our tails tucked between our legs so that they don't have to pay for WLS?!? I know it almost kept me from pursuing WLS at all because I figured I had no chance for approval. I don't know what to think now but I am going to try to get approved. Please let me know if you find out anymore information and I will do the same for you. Good luck. Tammy W.