Question:
Has anybody recieved approval from an ins. co when they had a written exclusion?

I have United Health Care and my policy has a written exclusion for gastric bypass. Has anybody got around united healthcare when they had a written exclusion? Any replys would be helpful!    — Kelley S. (posted on January 26, 2003)

January 26, 2003
hi kelley - i don't have the same ins. as you , but my humana ppo does have the exclusion . i won't see the surgeon until this may , but i have made sooo many calls to sak about this with ins. , they say if it is medically necessary , then there is the chance it will be covered , even with the exclusion . but i am a pessimist and expect they won't . i will wait and let my surgeon submit for approval . i do have all the problems (co morbids) that they say would make this medically needed . if i have a problem with ins and the wls , then i will go to my husbands work and talk to the pres . and v.p. about amending the exclusions , at least this once for me .have you tried to call up your ins. and ask if there is anyway they will cover ? if they won't for med. needed , then maybe you can talk to the owner of the company , they are the ones who say what they want covered or not , they can change it . good luck , i still am keeping my fingers crossed , maybe i will learn to be optimistic if i get approved ......
   — patti G.

January 26, 2003
Hi Kelly, my insurance has a pretty specific exclusion. They wouldn't even talk to me. So,, I wrote a letter to my Human Resource person who is also our plan administrator. She forwarded the letter to someone at BCBS. They called me and asked for my medical records. So in a way I went in through the back door so to speak. They told me they were reviewing my medical records for medical necessity and to see if the surgery was "cost effective" verses my current course of treatment ( I may be loosing my vision in my left eye). Can you imagine? Cost effective? How can anyone put a price on their vision! Anyway...they told me I would hear back in about a week. That was last week so hopefully I will know something by the end of this week. Wish me luck and pray for me. Don't give up. There are lot's of options. Hound not only the insurance company but your employer, too. But remember to be nice until you absolutely have to get ugly. Ginger
   — sweets1224

January 26, 2003
Hi Kelly, I do have United Health Care--choice. Yes they will tell you they do not approve it, but you need to have your PCP & Surgeon stand behind--all drs. The people who man the telephones can only read to you what's in front of them. Ask for the ph# to the appeals dept. That is who you need to work through. I hit the same road block 11/01 b/4 I even submitted my requst for surgery. I kept hitting the wall so I asked for appeals. The woman (Rebecca) was great, I never had to appeal, she made sure I was approved from the beginning. Also, if that does not work, Threaten them with a lawyer, as soon as my friend did that in Dec., they approved him. post op 1/24/02 185lbs.
   — Pamela S.

January 26, 2003
ps...Have your surgeon include photos and also all medical problems--make them up if you have to. Joint pain, back pain, difficulty walking, shortness of breath, etc.. If it's already documented on PCP files--make sure the surgeon includes that.
   — Pamela S.

January 26, 2003
I have United health care, I have bbeen fighting this for almost 20 years, not from the same insurance company but this is my latest fight..... I waited for an answer for 3 monthes from United health care.... when the y did get around to answering aout my claim... of course once again it is a written exclusion... DAMN!!!! anyway, this is what I found out.....if your policy has a written exclusion it is ecause your employer wrote that into the policy... it has NOTHING to do with the Insurance company....which means that unless you go directly to your human resources and talk to them there is nothing you can do....I have learned this from getting denied from 4 companies with this policy.... I even tried fighting it until a lawyer told me I don't have a case.... I wish someone cold tell me something different.... now I am waiting for my husbands human resource department to get back to my husband for some good news... fingers crossed... I don't mean to put a damper on things and if you know how to get around it Y A Y!!!! God bless you and keep trying!
   — sue C.