Surgery denied!

What if after a 6 month supervised diet your insurance company says no? 

Did they provide a reason? Is it because you now don't meet the criteria and did too well during the 6 month period?

Is it possible that they over-looked some of your co-morbities?

Is there an appeal process? But, just an FYI on appealing. Many employer-provided policies are "self fund" health insurance programs. That means that rather than being part of a true insurance "pool", your company is paying for each claim out-of-pocket plus a fee to the insurance company (who only acts as a clearing house / administrator for the policy).

With self-funded policies, your appeal may be directed to your employer for a final decision. That's what happened to me when I had my Moobs removed about 30 years ago. The doctor said it was a medical necessity and the insurance initially approved it. But, when the biopsy showed that only normal tissue was removed, the insurance company denied payment claiming is was cosmetic surgery.

I appealed the denial and, because it was a self-funded policy from my employer, I found myself pleading my case to local company management (who were all non-medical people). Needless to say I lost my appeal and I found myself in management cross-hairs.

Relations were strained and I eventually felt forced to find another job. In addition, I was saddled with some hefty medical bills for both the surgeon and hospital.

Things have probably changed in 30 years. But, if you have a self-funded, employer-provided policy then I caution you to carefully research the appeal process and make sure you consider the ramifications.

My claim was approved within 8 days.  My insurance coordinator  said that it got approved so easily because my primary care doctor wrote a detailed letter explaining why this surgery was important for my health.  Also I only lost 2 lbs out of the whole six months of the doctor visits. Documentation of my exercise and diet were Throughly mentioned in my doctor notes.  Just appeal it.  In the medical field, ITS ALL ABOUT DOCUMENTATION.

Good luck.

Thanks, I plan to appeal, just trying to get as many opinions as possible.

Thanks again!!

 Agree with other posts, you need to appeal.

How much have you lost under the Medical program?  What is your current BMI?  Do you have other co-morbidities?  Your surgeon's office should really help with the appeal.  They should know what it takes to get this covered for you.  Let them be your advocates.  If they won't, you may want to consider finding a good surgeon who will.  Good luck and keep us posted on your progress.  Mike

As some others have pointed out, if the medical weight loss program is successful, if it causes you to lose substantial weight, the ins. co may decide "gee, this guy doesn't need surgery." It's so perverse, because we all know that you'll eventually gain back the weight you lost.

There's almost an incentive to not take the medical weight loss program seriously.

My insurance denied me after jumping through every hoop they asked for.  I thought it was a year wasted.  BUT, after a little questioning, and some help from my HR dept at work, they got it fixed and I am 8 months out and 160lbs lighter .  Do not give up, keep fighting.