Question:
ANy suggestions on how to appeal an insurance exclusion for surgery?
I have a BMI of 53, high blood pressure, sleep apnea, and acid reflux. However, my insurance policy has an exclusion and I can not afford to self pay at this time. — sealscr (posted on November 18, 2009)
November 18, 2009
Cheryl, I'm not an expert but I've not heard of overturning an exclusion
those are pretty firm. My old insurance excluded everything but the lap
band but thats not what I wanted so I waited. My new job covers it all.
Best of luck!!
— kmom1420
November 18, 2009
I feel your pain. I am wondering the same thing.
— SoleAbstrakt
November 18, 2009
Go to obesityaction.org. They give advice on how to approach the insurance
company to overturn a denial. They also have sample letters you can use
and have your physician send in to the insurance company to assist you in
overturning that denial. I wish you the best. God Bless.
— KimM
November 19, 2009
As other posters have said, exclusions are pretty difficult to deal with
because these are different than a regular denial. I would suggest looking
into getting a different insurance company and also checking out
obesityaction.org for suggestions. In the meantime, keep getting your
monthly weigh-ins in case you will need them with a new insurance company.
Best of luck!
— eyeflirt4fun
November 19, 2009
Most insurance companies have instructions on how to appeal decisions in
their own brochure/handbook as well as online if they have a website. If
you are not a federal employee, you may want to consider appealing to the
general attorney in your state as well.
— cydthekid50
November 19, 2009
My job had the same exclusion with the insurance co... I fought for six
years even changing jobs for different ins companies and going from my ins
to my husbands insurance also. If it is a set exclusion, there is not much
hope I am sorry to say. I had high blood pressure, diabetes, sleep apnea,
knee and joint pain, yadda yadda and no luck. I did finally get to self pay
for the sleeve procedure in June of this year and have lost 102lbs as of
today. I had my procedure in the Dominican Republic and loved my surgeon!!
He was and is amazing we still keep in contact and I have all of his phone
numbers including his personal cell. I paid right at 10,000 for the
procedure. Sorry to give such bad news, but I wish you the best of luck on
your journey!
— callen3640
November 19, 2009
All insurance companies have that exclusion. Your primary doctor needs to
send a letter with a lot of other information from the bariatric surgeon to
the insurance company "Deeming it medically necessary" for you to
have this surgery. If you need more help, please just email me. It has to
be done in a manner that all your paperwork is included, and all the hoops
you have to go through on the insurance end of things. But in order for it
to be "approved" the doctor has to deem it medically necessary.
Hope this helps.
— Kristy
November 19, 2009
I just posted, but I forgot to mention it depends on if you have already
put in for approval, but a lot of insurance companies will only cover RNY
or DS. As an example. My insurance co only would cover the RNY so that is
the one I went with plus it fit my needs. If you do get denied, reapply
only this time for a different one. They find that these are experimental.
Although this is the way it was 5 yrs ago, insur com are finding that they
aren't experimental and more people are getting approved. don't give up if
you do get denied. Just find out which surgery they will approve. They
will approve it if your dr says you need it.
— Kristy
November 20, 2009
I had an exclusion in my policy too and I fought them for 3 years and
didn't budge...I had Rheumatoid arthritis, high blood pressure and all of
the bad things that go with obesity and I appealed 4 times and they
wouldn't budge. If its an exclusion, there is really no hope....Sorry to
say, good luck and don't give up. I finally had to get a loan and pay for
it myself.
— okbuffy
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