Insurance Exclusion

If your insurance company does not cover gastric bypass and it is an exclusion in the policy, is there a way to get them to approve the surgery?  Any idea would be very helpful.  Thank you.

I just read on another board about a woman who got approved because she had serious esophageal reflux unresponsive to medications; she needed surgery to fix the huge hiatal hernia she had but they wouldn't do surgery because she was so overweight.  So she appealed and won.

An insurer not covering weight loss surgery or qualifying coverage to eligibility based on a variety of factors is quite different than an exclusion which could be an insurer issue (based on “medical necessity”  “investigational procedures” etc.) or it could be an employer exclusion.  Generally speaking, it is easier to beat a coverage issue than it is to win an exclusion issue.  For example Aetna (the insurer) has policies that cover WLS, however, whether or not that coverage is available to you as an employee of Company ABC is completely dependent on whether or not Company ABC chose to include that rider in the package they selected for their employees.  I have Aetna Open Access Select through my husband.  His employer, which is a well know world-wide operation whose North American Headquarters are in Redmond, offers an excellent benefits package...but all weight loss surgery regardless of BMI, co-morbidities, etc is specifically excluded because the employer chose not to include it due to cost.  We have written a letter to his HR department but it s unlikely that coverage will be added due to the premiums associated with the WLS insurance rider.

Regarding insurance in general, it is important to keep in mind that many policies that do cover WLS require all covered individuals to jump through numerous hoops before approval is granted regardless of co-morbidities, BMI, etc.  It is not uncommon for individuals to have to be on a medically supervised weight loss program for between 6-12 months before eligibility.  Once eligible, there are numerous people who have still had to battle the behemoth corporate insurance companies to get approval.

 

 

That said, if you decided to use your insurance to pay for WLS, please know that you are your own best advocate.  Your surgeon may have an “insurance coordinator” who submits authorizations, tracks declines, etc.  Your family physician and surgeon may be should be willing to help you obtain approval by writing letters, providing chart notes, submitting claims in a timely manner, etc. Ultimately, though, as you are the one having the surgery, it is in your best interest to contact the insurance company directly to get a list of eligibility requirements, call to verify that they have the information needed, and prepare and mount a appeal if your claim is denied.  There is no getting around the fact that relying solely on middle persons too often leads to misinformation, delays, etc.  Every time you speak to your insurer, note the date, time, person you spoke with and a brief synopsis of the discussion.  That information is vital should an appeal ever be necessary.

 

 

Of course if you are one of us whose insurance absolutely will not cover WLS, there are alternatives available to self-pay patients.

Many surgeons offer a "low" cost self-pay package, but one must be aware that the cost of such packages does not typically include pre-op labs/exams/consults nor follow-up care beyond 30-90 days.  Depending on the surgery chosen and the surgical risks of the patient, those costs can be quite expensive and may or may not be covered by any medical insurance carried by the patient.  For example, I am getting the sleeve (VSG) on 11/19 and my surgeon, given my medical history and BMI, ordered 24 labs, 8 tests (ultrasounds, stress test, etc), and 4 consults.  My insurance should cover all of those but I am preparing to battle if denied.  I just confirmed that my insurance will also cover any complications that result from surgery.  Required follow-up can be more expensive than the surgery itself; the extent to which is dependent on the specific surgery chosen ( for example, frequent labs to monitor nutrition for bypass patients due to the malabsorbtive nature of the procedure or the cost of fills for the Lap-Band). 

Medical loans / financing are available.  The interest rate is appalling but if it's the only option, it's nice to know it's available.  One company that offers such loans is http://mymedicalloan.com/.  You may also be able to secure a loan through your bank depending on your credit history. 

Finally, Mexico is a lower cost alternative to local surgeons.  However, there is no follow-up with the surgeon once you leave Mexico.  Depending on the type of surgery chosen, the cost of follow-up back in the States could be quite expensive.  This option also requires that one be comfortable with having a major medical procedure outside of the US without an opportunity to meet face-to-face with your surgeon until literally just a day before surgery and having the labs, etc done after you’re in Mexico and again, just a day before surgery (I’m curious to know what happens if the labs/exams come back indicating that you can’t have surgery at that time).  Don’t get  me wrong,  I think it  is possible to get very good medical treatment in Mexico, however, given the lack of access to the surgeon and follow-up issues, I would be very careful about selecting this route especially if you have a high BMI and co-morbidities that increase the risk of surgical complications.

I wish you much luck in your quest,

Amy

I have been battling this issue for over 5 yrs now. Both my insurance and my husbands have direct exclusions for any/all weight loss.  So it will not be covered. No matter the co-morbities, or risk factors.  I have yet to find out or figure out for that matter, if there is any reason to have Bariatric surgery other then for weight loss.  As the only way it might be covered is if its for non weight related concerns.

If anyone has a answer to the above I would like to know as well.  At this point IM looking at paying for the surgery out of pocket, and that will be some time, as I need to save. 

Thanks,

Kathy