Is Bariatric Surgery Considered A Weight Loss "Program"?

I sent this question to Mr. Viscio, but in the meantime maybe you guys have some thoughts. I don't have a denial yet, but my employer has an exclusion that states, "Weight loss programs whether or not they are under medical supervision. Weight loss programs for medical reasons are also excluded." I had the Lap Band on 9/15/05. The preop information was submitted to United Healthcare about 2 months before the surgery. I received the following letter from the UHC Case Coordinator. "XYZ" will stand for my employer: (Note: I posted the text of the letter before, but at that time I had not seen XYZ's exclusions.) "We have completed our review of your request for coverage of morbid obesity surgery under the "XYZ" benefit plan. Based on the information reviewed, we are pleased to inform you that coverage is available. All covered charges are subject to screening for allowable charges. The final allowable charge will be determined when the bill is submitted and will be based on the actual service(s) provided. Please note, this letter does not guarantee payment. Benefit payment is based on the provisions of the "XYZ" benefit plan and is subject to the guidelines, plan design, and policies effective at the time of service." Then they have another paragraph about me being a valued customer of UHC. Would Lap Band surgery be considered a weight loss program and therefore excluded? Thanks in advance.

I hope I'm understanding your question correctly......This letter looks/sounds like an approval which would mean that it is not excluded. Otherwise it would've said you are DENIED. Plus Lap Band is an actual procedure not a "program". It sounds like they are referring to WW or JC. Maybe you should call your insurance company to clarify the letter for you. All the insurance company approval letters sound like this, mine did. I was so confused as I didnt know if I was approved or sordove or approved or what . Thank god I was approved! Either way, congrat's on your recent surgery.

From what I have been able to gather, an insurance company may cover a certain thing, but depending on how CHEAP one's employer is, he may choose to buy a policy that specifically excludes that certain thing. It's stupid I know, but that seems to be how employers cut costs... at their employee's expense.

lol..Your so right about that...they will cut costs at our expense go figure. Did you self pay or did they cover the Lap? I remember reading a post where someone self paid and then submitted a claim to their insurance. I think after a couple of appeals she as able to get some of her money back but not all of it because the insurance company only paid their negogiated rate. They're horrible

I'm waiting for the hospital to submit their claim to UHC. Then we'll see if my employer will let it go through.

I got the same approval letter. Yep, you have been approved! We have UHC Choice Plus and they would not cover anything BUT surgery. No weight loss programs, no drugs, nothing. (My hubby says it is because they knwo that they don't work.) When I called to verify my benefits I asked if Lap Band was approved along with the RNY and they said yes it was. There shoudl be a name of your care coordinator and a telephone number. Call them to double check. I was approved within 3 days of my paperwork being submitted. Best of Luck!

OOPS! I kind of read this wrong. Your surgeon should have verified yoru benefits before your surgery so I am confused as to why you had your surgery on the 15th and then got your letter.

Yes, the surgeon verified coverage with UHC before the surgery. I received the letter from UHC before the surgery, but at that time I had not seen a copy of my employer's specific exclusions. Even the UHC letter states that coverage is not guaranteed and depends on the employer's policy. From what I have been able to gather, an insurance company may cover a certain thing, but depending on how CHEAP one's employer is, he may choose to buy a policy that specifically excludes that certain thing. Some employers tend to cut costs at their employee's expense. So I just thought that instead of having a false sense of security and thinking that it would be covered, I would just see if anyone had any experience with weight loss surgery being considered a "program" so that the employer can get out of covering it.

Ha this is so wild. I have UHC and I have the exact quote in our policy. However, I hope I am hearing you correctly. They paid for the surgery and now they don't want to cover the bill. Is that Correct? They have paid for all of my pre-op stuff, but I haven't had mines submitted yet. Hopefully, sometime this week. When I called them they told me it was a billable service, but that doesn't mean that they will cover it. I say fight for it. The proof is in the letter.

The hospital hasn't submitted their bill yet. UHC makes a point that the letter is not proof of coverage. I'm keeping my fingers crossed.