Total Exclusion - Yuck!

Hi everyone, I am a new member to this site, love it so far! I recently found out my insurance company has a total exclusion for any weight loss management! So I will have to save for the money. I am looking into the Roux-en-Y gastric bypass surgery. Anyone out there facing this problem? Laurie C.

Hi Laurie Mine had the same thing but my surgeon proved that it was a medical necessity.so they approved it.so try going this route Cathy

All I can say is fight, fight, fight. It can be fought and won in some cases. You can also check with an attorney for filing an appeal. A lot of people have luck going that way. I have heard they charge about $450.00. Good luck. JC

I too have your problem! My exculusion was very explicit. There was no way around it. Can't even appeal! So I am self-pay. On the positive side you don't have to wait so long for scheduling! Several doctors have programs set up for self pay. Mine is Dr. Chang in Victoria. Good Luck! Cindy

If you appeal, you are only out time and the cost of a stamp! Can you email me and tell me, word for word, what your policy says? Sometimes it's not what the policy says, but what it doesn't say! If they can make you believe surgery is not covered, then they win! (I work for an insurance company.) Sue Kennedy

Hi Sue, My insurance company is Great West - PPO. Under the section "Medical Expenses Not Covered", it states "Any treatment of obesity, including gastro-bypass surgery". I also called them to further verify this, and they confirmed even if my doctor deems it medically necessary...NO COVERAGE! Thanks so much! Laurie Campbell

I sent you an e-mail Laurie, but I will post my response here, too, ina nutshell. The exclusion is for the treatment of obesity, not MORBID obesity. If you call and ask if that is the case, of course they will say it is. Write a letter and assume that the surgery IS covered for the treatment of MORBID obesity, and ask what the criteria is. Sue

Hello my name is Tabitha.I was reading your comment and wanted to ask you if you could review how my exclusion is written and let me know what you think. It reads as below

For bariatric surgery,regardless of the purpose or performed.This icludes but is not limited to Roux-en-Y (RNY?), Laparoscopic gastric bypass surgery or other gastric bypass surgery (surgical procedures that reduce stomach capacity and divert partially digested food from the duodenum to the jejunum,the section of the small intestine extending from the duodenum), or Gastroplasty,(surgical procedures that decrease the size of the stomach),or gastric banding procedures.Complications directly related to biatric surgery that result in an Inpatient stay or an extended Inpatient stay for the bariatric surgery, as determined by Us, are not covered.This exclusion applies when the biariatric surgery was not Covered Service under this Plan or any previous Anthem plan,and it applies if the surgery was performed while the Member was covered by a previous carrier/self funded plan prior to coverage under this Certificate.Directly related means that the Inpatient stay or extended Inpatient stay occurred as a direct result of biariatric procedure and would not have taken place in the absence of the biariatric procedure.This exclusion does not apply to conditions including but not limited to: myocardial infarction;excessive nausea/vomiting;pneumonia and exacerbation of co-morbid medical conditions during the procedure or in the immediate post operative time frame.

Please just let me know what you think.

Thank you!

then I met a lady in the restroom at work who said she'd lost 165 lbs in a year, I said what did it cost, she said our insurance covered it because of medical necessity! We filed my paperwork yesterday! I'll keep you posted on the outcome!