Question:
Can my insurance deny surgery even if it's a covered expense?

Last week, the receptionist at my surgeon's office faxed over my clinical information for review to my health insurance plan. I was told that it goes to review for 7-10 days & I will get a letter either telling me if it has been approved or denied. I got out my insurance handbook & surgery for morbidly obese is a covered expense. Would there be a reason that I could still get denied? I do meet the criteria which states that I have to be 100 pounds or more over weight. My BMI is 40.    — Lori M. (posted on July 23, 2001)

July 22, 2001
Hi Lori, unfortunately they can still deny your request although it's covered. Your profile doesn't say what type of ins you have, but I had BCBS PPO and was denied twice even though my BMI is 52 and I have several comorbs. Although it's covered and your BMI is 40, if you have no life threatening comorbs you may be considered a "healthy fatty" to them and they may deny. Some ins cos are better at approving than others, so be positive. If you have life threatening comorbs such as sleep apnea, make sure the relevant doctors write letters to the ins co on your behalf and recommend WLS. All the best.
   — dandjon

July 22, 2001
I have a BMI of 52 and no life-threatening co-morbs other than GERD, joint pain and back pain. I am considering having a sleep study done to conclude whether or not I have sleep apnea. I have been denied twice, regardless of my diet history or family history of high bp and diabetes. The first time I received a denial I requested the criteria my insurance used and if you go read on my profile you will see it is ridiculous. They use it to exclude without actually putting the exclusion in the policy. I have decided to hire an attorney to handle my appeal from here on out. My company is self-insured, and although the insurance is merely an administrator, the insurance still sets the criteria to be used. If you can, before you receive the denial, find out what situation you are in. If you are dealing with a self-insured policy, you can go to your employer and ask them to overturn a denial after you receive one and allow coverage for your surgery "out of contract." Get a copy of the NIH guidelines to back you up. Arm yourself with knowledge, i.e. the proper filing methods for claims, appeals, etc. Make certain you have all your bases covered. If you get approved, great, but if not, you will be prepared.
   — Diana M.

July 23, 2001
You should be aware that it may be your medical group that approves or denies, not necessarily the insurance company. I had to change my PCP so that I could get a referal to see a WLS surgeon. But, since you have already seen the surgeon, this is probably not the case for you. If you meet the criterea and it is a covered expense, I would think you should not have a problem. With a BMI of 40, you should not need any comorbidities to qualify.
   — Gina E.

July 23, 2001
Hi, this is Lori. I guess posting my insurance company would have helped answer the question I asked. I have First Health Network insurance thru my husband's employer. And the only problems I am having is reflux & lower back pain. Nothing else. I have been on numerous diets & programs for the past 15 years or so (I am 36) losing weight only to gain it back & plus more. My insurance handbook specifically states "Surgical Treatment of Morbid Obesity" is a covered benefit & limited to 2 procedures per lifetime. Thanks for everyone's help in this. I just don't want to get my hopes up only to be disappointed if & when I get my denial letter.
   — Lori M.