Question:
This is what my policy says about wls...is it a lost cause??

My policy is pretty vague. Out of 51 exclusions & limitations, this was number 49 and it is worded just like this..."any gastric and/or other intestinal surgical procedure for the purpose of treating obesity is not covered." Okay guys, give me some hope here. It doesn't say "morbid obesity"...and I have numerous health problems specifically related to my weight, PLUS I have a wonderful, two page letter from my pcp saying its MEDICALLY NECESSARY and I should not wait any longer than necessary to have my VBG done. (Is the VBG considered an "intestinal" procedure??) It also states that "no items under the exclusions and limitations list shall be covered unless it is "reasonable and necessary for the diagnosis or treatment of an illness or to improve functioning of a malformed body member or for maintenance of the health of a member." If anybody has a malformed body, its ME :o) Anyone wishing to decipher this mumbo-jumbo for me and speaketh to me in English?? Thanx! :-)    — Linda J. (posted on August 29, 2000)

August 29, 2000
Hello Fellow Wisconsinite... I would appeal... I would also contact Walt, and ask him his thought... pokie
   — Michael (pokie) F.

August 29, 2000
I think many, if not most, insurance policies have some kind of worded exclusion for wls (any type). However what they usually don't say, as your does, is that there is an exception for "medically necessary." Have you submitted the surgeon's letter yet? Have your surgeon go ahead and submit the letter. In my case, although my policy did have an exclusion, I was approved in one week, based solely on the first letter my surgeon's office sent. I don't think it is a lost cause, especially since your policy states that the exclusions may not apply if medically necessary. Best of luck!
   — Robyn L.

August 29, 2000
Dear Linda, Glad you got the letter from your pcp. That's an asset. I think the language of this policy is to your advantage. To me it sounds as if the approach you must use in order to be covered is your co-morbidities. Your thinking is on the right track. They may treat the morbid obesity issue but I would bet the easiest and fastest way to get this through is to avoid mention of that and go with the comorbidities. Hopefully you have lots of data on how serious these are or how much difficulty they are causing you. I would go with the treatment of an illness clause and the maintainance of health clause. If I can be of any further help Linda you can e-mail me...We have talked before. Best wishes and hugs...
   — JennyLynn A.

August 30, 2000
8/30/00 my insurance had different wording, but the book said no surgery for weight loss will be covered. I called them and gave them the diagnosis code # and the procedure code# (you can get your Dr. office to give you that). They told me that it would only be covered if medically necessary and letter of medical necessity and documents supporting medical necissity must be submitted. long story short I am having surgery October 10. They hope most people will read the book and see that it is not covered and stop there. Then they hope that if you see how much work and paper submission you need you will give up. If you jump throught all the hoops and are persistant it may very well pay off. You should proceed as if you are going to be covered and do all the submissions, etc. get all your ducks in a row. If you need xrays, sleep studies, blood work DO IT. Get copies of all your medical records and bring them to the surgeon. I did alot of footwork and organizing myself. good luck to you
   — claire C.