Question:
I was reading my benefits book and...

I haven't yet went for my consultation, I first have to attend a mandatory informational meeting on Monday and then I will be scheduled for a consultation. I've been very nervous that for some reason my insurance won't cover this surgery even though I have a BMI of 57, high blood pressure, pain in my joints and difficulty breathing at times. I was reading my benefits book and it says under services that are not covered: "weight reduction programs, including all diagnostic testing related to weight reduction programs, unless medically necessary and appropriate." Is WLS considered a "weight reduction program"? Does this mean that if my PCP and/or surgeon feels that WLS is medically necessary that having it covered by insurance won't be a problem?    — Rhonda Y. (posted on March 11, 2003)

March 10, 2003
What you are missing is the "unless medically necessary" term. I believe this term will help you out alot.
   — Angel S.

March 10, 2003
Be sure to check all the exclusions. WLS is not a weight loss program! A weight loss program would be something like Weight Watchers or Optifast, and even then, it says "unless medically necessary." This sounds like a rather liberal policy, so I would think you would not have any problem getting WLS covered!
   — koogy

March 10, 2003
My insurance has a similar (almost exact) exclusion. Check under the surgical procedures and see if there is a benefit for surgical treatment of morbid obesity. Mine did and I'm now 3 months post op. Good luck.
   — Lisa S.

March 11, 2003
Rhonda: I don't think they would consider WLS a "weight reduction program." But check it out with your ins co. My benefits book states the following under the section "What is Not Covered: You are not covered for Hospital, Medical-Surgical or Major Medical services, supplies or charges: for treatment of obesity, except for surgical treatment of morbid obesity when weight is at least twice the ideal weight specified for frame, age, height and sex." OK - to me this means that if my ideal weight is 150, I would have to weigh 300 to qualify for surgery. I weigh 258, so don't qualify, right? Well, I decided to look into it further, and called my insurance co's customer service number. I requested a letter stating the coverage benefits available for gastric bypass surgery, and what other qualifications must be met. It took them a couple of months to get the letter to me, but it states that gastric bypass is a covered benefit, for a diagnosis of morbid obesity. Morbid obesity, as defined by my ins co, is a BMI of 35+, being 100 pounds overweight. Well, gee, I guess I meet that criteria! But if I had just gone with what the book says, I would have thought it was not covered! So, definitely, check with your insurance company, and get a written clarification from them as to what your benefits really are. After I received this letter, I felt much more comfortable with scheduling my consult, and preparing to go forward with pre-op tests, etc. Good luck to you!
   — Carlita

March 11, 2003
Rhonda, I was going to say the same the previous posters said, it does say unless medically necessary. And at a BMI of 57 with your co-morbs, I def. believe it is medically necessary. I was very nervous, too about getting covered. I had a BMI of 45, but nothing seriously wrong with me, and I was 22, so I didn't know what to expect. I got covered from AETNA within a few weeks. Just think positive and get medical letters from your PCP, write a personal letter yourself as well. We had to, but I don't know if everyone else does, I think it helps. You honestly just never know with insurances, but keep on them and don't give up. You seem very qualified to have this surgery. I wish you the best!
   — Lezlie Y.