Question:
Exclusions?

This is exactly what my insurance manual states: Weight Loss: services and supplies to treat obesity, weight loss or dietary control even if they are part of the treatment plan for another sickness. But the Plan may cover some services and supplies for weight loss if the Claims Administrator determines that these services and supplies are Medically Necessary based on its evaluation of your body mas index (BMI) and health status. So my Questions is, does this mean that the will cover Weight Loss surgery? Has anyone else been approved with this as part of your policy? Thanks for any input. Joanne    — Joanne B. (posted on April 30, 2002)

April 30, 2002
After reviewing the information that you posted: I feel that they are not stating that surgery for morbid obesity for a Gastric Bypass is an Exclusion ; they are stating that it needs to be proven medically necessary. Which should be done by your surgeons office. They should do a Pre-Determinatiion. Thanks, Beth
   — Beth M.

April 30, 2002
It is my opinion that your insurance can choose to cover it IF it is medically necessary . In addition to a BMI over 40 you may have to show you suufer from diabetes, HBP, etc. You are fortunate your insurance provides a window of opportunity for surgery approval.
   — Linda M.

April 30, 2002
This is a very vague exclusion. However it does not state that surgical treatment is not covered. And it also states that they will cover obesity treatment if they feel you meet certain criteria. I would view this as a positive had it been my policy.
   — RebeccaP

April 30, 2002
I just asked a similar question last week! Mine was almost worded the same. Just to double check, I emailed the customer service at Aetna. THey said WLS is covered as long as it is approved prior. I think as long as your surgeon submits ahead of time, you'll be fine. Check with the insurance company though.
   — emilyfink

April 30, 2002
My interpretation is that if you have serious weight related health problems, it should cover WLS. Sounds like with "BMI and Health Status", they are open to covering WLS if you meet the criteria. I see from your profile that your BMI is 39, which will be a tough sell to get WLS, because the criteria used is usually over 40, but will cover over 35 with severe weight related health problems. Bet you never thought you might be to thin? But give it a try and submit it. Like I said, it will most likely depend on how serious your comorbidities are.
   — Dell H.