Question:
Anyone had insurance cover RNY when it was an exclusion on the policy?

I am getting a bit more than discouraged.... :( The hospital called my insurance company and they said that with the 6 month dr supervised diet and the countless other things they would cover the RNY...I have went through everything, jumping through hoops for what feels like forever only to get told that weight loss surgery is an exclusion on my policy even though it is medically necessary for me. Has anyone ever fought the insurance company and won the fight?? I just really need some help and advice on where to go from here! If it helps I have BC/BS. Thanks for any help!    — mensing03 (posted on January 26, 2010)

January 26, 2010
Hi Bobbie, I had BC/BS of California when I had my RNY done 4 yrs ago. All insurance company policies have that exclusion. But....just because your doctor deems it medically necessary might not be enough. Do you have the co morbidities (life threatening) conditions in which they can prove to the ins. company. that your life is at danger unless you have this surgery or being 100 lbs overweight usually not always automatically qualifies you as a candidate. If you have high blood pressure, GERD (acid reflux), high cholesterol, diabetes, these will help. Not just having it in your family history is enough to qualify you. But you need to have some not all of them to qualify. I have a lot of them, was 90 lbs overweight, got denied the first time, due to lack of info, got denied, resubmitted paperwork and within 3 weeks, got approved. Have the surgeon send in your paperwork. Every "I" has to be dotted and every "T" has to be crossed. Once your Primary doct and the bariactric doctor deem it "medically necessary" you should get somewhere faster. Maybe I missed something in your post, but just because they have that exclusion "they all do" that just means also, that they won't pay for "say Liposuction or tummy tuck" as a form of weight loss surgery. I don't know how far you are or what your medical history is like but that would help us to help you more.
   — Kristy

January 26, 2010
Kristy hit it on the nose. I went through 6 month preop diet, had two comorbidities but was approved. A coworker who has the same ins as me was denied but fought back (she's an attorney and knows how to do it!) and was later approved. Good luck.
   — Muggs

January 26, 2010
Hi Bobbie: I, too, am going through the same process you are. I did have bc/bs and they had approved it, but had two months left to do the supervised diet, and then my husband lost his job and his insurance. I have insurance through my work, but it is Health America, and they have an exclusion in their policy too, that they won't cover it. I don't know what to do. I am sooo frustrated, I have cried, and now I just do not know whether to pursue it or not. Let me know how you make out. Good luck.
   — Priscilla V.

January 26, 2010
Hi Bobbie, I don't have bc/bs but mine also is listed under exclusion. I didn't have many medical problems fast heart rate & sleep apnea only but my insuracne company wanted 6 mo monitored diet, 5 years weight history, and previous attempts of diets tried and failed. I met all the requirments and had RNY gastric bypass on 12/28/09, started at 245 lbs & down 30 lbs already.......a few little minor complications but on the road to getting this off once and for all. Like anything else.......you have to jump through the hoops they are requesting and your Drs. office should let you know what those hoops are. Best of Luck to you
   — 3decks

January 27, 2010
I have to disagree with Kristy. All insurances do NOT have exclusions. There are many who approve easily, many who have you do 6 months to one year medically supervised diet,other that exclude unless proven medically necessary, all gamuts of restrictions. But for those that DO have EXCLUDED, period, written in the policies then you are out of luck. Excluded is just that, excluded!
   — corky1057

January 29, 2010
My insurance excludes it also. Sent in all medical info and they simply sent back their exclusion waiver. So, I "appealed" and they wrote back I cannot appeal and defined "appeal"---denying payment---I could not appeal as I did not submit a claim. Well, I paid myself, and intend to send the bill to them and go forward from there. Never stop fighting! Good luck to you!
   — Tish C.