Question:
confused about wording of my policy

obesity surgery is under the exclusions section but as you read on it states unless med necessary, does this mean i have a chance of approval or is it hopeless, i have Cigna HMO and am waiting for approval.    — roxxyblue72 (posted on January 10, 2003)

January 9, 2003
You may have another loophole if the policy says surgery for the treatment of obesity. The WLS is for the treatment of MORBID obesity.
   — John Rushton

January 9, 2003
"unless medically necessary" means that with this surgery, your helth will improve, ie: comorbidities will get better. So, IF you have comorbidities that will improve with weight loss, you have a good shot at getting this covered.
   — Vicki L.

January 9, 2003
My insurance says the same thing, and I called and they told me that they will cover it if my PCP deems it medically necessary. Which basically means if you have a doctor that considers you significantly overweight, with enough commorbids,and is willing to give you a letter stating medical necessity, you should be jusst fine. Call you insurance just to be sure.
   — Laydie K.

January 10, 2003
i think most of our policies stated the same thing, but there is a difference between obesity and MORBID obesity. As long as you are 100 pounds overweight and/or have a BMI of at least 40, you are MO. That wording- obesity v/s morbid obesity is key! You definitely have a chance as long as you are MO. Call your insurance company and ask them specifically if they cover surgery for MO and what all they need for the approval process. No matter what, DON'T GIVE UP! Fight, fight, fight! Best of luck!...Karen (lap rny- 9/20/02- down 98 pounds!)
   — karmiausnic

January 10, 2003
Usually "medically necessary" as used for this purpose is defined in company policy, or actually in the insurance policy. If it is in the insurance policy, continue reading the exclusion and see if there is a definition section. If not, ask the company for a definition. <br> According to the National Institutes for Health (in MD) and the MD and VA mandates, weight loss surgery is "medically necessary" if the individual is 100 pounds overweight, has a BMI of 40 or more, or has a BMI of 35 or more with significant co-morbids (eg sleep apnea,GERD, Diabetes Type II, heart disease). However, some insurance companies (writing policies outside of MD and VA) simplify the definition to mean either a BMI of 40 and/or being 100 pounds overweight. <br> If you can get the definition of "medically necessary" from your insurance plan, follow that definition in making the case that your surgery is medically necessary. Use the terms used by the insurance plan, so that even the lowest level employee can see you meet the definition. For example, if the policy says "sleeping disorders" are comorbids, and you have sleep apnea-- don't say just sleep apnea, but "sleeping disorder, sleep apnea". <br> Good luck!
   — Beth S.

January 12, 2003
My insurance said the exact same thing. As long as my PCP determines it is medically nessessary...I'm good. Tomorrow I go in for blood work to determine if I have a metobolic disorder (Hyperthyroidism), diabetes, and other stuff. After that, I think (GOD WILLING) my doctor will write his letter of nessessity to the insurance company. I'd call your insurance company, explain to them what you'd like to do...ask them what they require of you for coverage. I'm sure they'll help you out.
   — Renee B.