Insurance Reimbursement

I am in Ohio and had surgery in May of 2009.  My insurance company, Anthem, said that I had an exclusion on my plan and it has taken me this long to get any type of response to my appeal from them.  I  have 4 letters of medical necessity from my doctors and would probably not live much longer without my surgery.  This was the best thing ever but am trying to have my insurance company help pay for this wonderful, life saving surgery.  Has anyone been able to appeal your insurance company and do you have any advice??  Thanks...

Each policy is different it's up to the EMPLOYER to choose what is allowed and what is EXCLUDED. You should have tried to get your employer to change the policy before you WLS. if it was an exclusion and you went ahead with the surgery I bet it will be all out of pocket.  I'm sure you got a letter of denial as to why they would not pay, most cases you just have a few months to appeal 30-60-90-180 days.
Good luck,
Robin

The employer's changing the plan was not an option and I didn't have any time to make changes before my surgery.  It is all paid for because I felt terrible for more than five years and had to make the decision to have the surgery to save my life.  I am the only one in my support group that paid out of pocket and feel that it was a necessary step that I took.  My appeals process is in the works, but because we work for a small company, we could not change the plan and it is a huge financial burden to have paid for the surgery because my health insurance is more than $1000 each month, out of pocket, too..If anyone has any suggestions, I am here. 

I've seen appeals won, however I've not heard of them winning in Ohio, not that it can't be done.  I've been around for a long time and have seen many appeals happen and overcome.  I know of one gal in Alabama who fought BCBS to reimburse her for her costs of going to Mexico for the DS because they refused to cover it.  One loophole you can try is using the term "Morbid Obesity" and holding them to that term.  Many contracts exclude "obesity surgery", but morbid obesity is often different in coding.  See if you can get an independent review panel involved.  These are just what I've heard successful people doing.  It might be time to get an attorney too.

I wanted to second Valerie's advice and to point out that if, by chance, you originally weighed enough to qualify as Super Morbidly Obese (BMI of 50 or over)  and you use THAT termionology, it might increase your chances of winning.

Lora