Question:
How do I get started with a exclusion

I need to correspond with someone who has recently been successful in getting approval for their surgery even though their insurance through their job had a weight loss exclusion. What is the first thing that I do to get started? I wrote the company (Aetna) themselves and of course they advised I can't get around the exclusion. Is that considered my first denial? Or should I go to a seminar and choose a doctor and then go through that doctor? I have no idea how to get started and some of the people I have emailed a few times have not gotten back with me and I don't want to bug anybody, but I don't know what to do. I am interested in having the lap band surgery rather than the gastric bypass. So if anyone has the time and patience, please e-mail me. Thanks.    — Donna W. (posted on May 25, 2005)

May 24, 2005
First thing you gotta do is go to the HR department where you work--the exclusion exists at your place of employment---which did not buy a rider that include weight loss surgery. You will have to appeal to them--and honestly---some win and many lose but surely take your shots at it. Ask them what you need to do with an appeal regarding and exclusion on your policy. They probably have forms to fill out and you will need to get documentation from your doctor etc. My company had an exclusion and there was absolutely no way around it. They would not give one bit. I instead went through vocational rehab which paid for a large portion of the surgery and I had to pay a share based on my wages. Good luck to you--never give up fighting! Lisa
   — Lisa4kds

May 24, 2005
Donna, I had the same problem - only with two different insurers, appealed to my husband's employer, spoke with an attorney who specializes in fighting insurance denials - and in the end, ended up self-paying and going to Spain to Dr. Aniceto Baltasar for my surgery. It was really almost a relief to be able to self-pay - after months upon months upon months of fighting for coverage, wasting valuable time, going through emotional hell - well, I now consider my insurance denial a huge blessing! I ended up with one of the best bariatric surgeons in the world doing my surgery, losing 210 lbs, regaining my health and life. Also, be sure to really thoroughly check out ALL of the different forms of WLS done. www.asbs.org is a good web site, and I like the excellent comparative chart found at http://www.dssurgery.com/generalinformation/comparison.php Have you considered the sleeve gastrectomy surgery as an alternative to the band? Anyway - you might want to consider whether or not you want to hire an attorney to help you in your fight. Of course there is no guarantee, but if you're willing to fight - great person to have in your corner! Best of luck to you! Blessings, dina
   — Dina McBride

May 25, 2005
Donna, a friend of mine just posted this on our board and thought it would be useful to you, darlin! Hope this helps some. Erika Almost every week this comes up and some have missed my post so I will try & post this periodically. If your insurance policy has an *exclusion* for WLS, go to the your employer Human Resource department and ask them if they are *self-insured*. If that is the case, they *sometimes* will take a look @ each case individually. The reason the insurance companies are excluding WLS is because of the HIGH risks involved with the surgeries and please understand...FIRST and FOREMOST... insurance companies are NOT in business to lose money! Your next step is to contact Walter Linstrom. He had the bypass surgery and has dedicated his law practice to helping folks with insurance company and state rehab commission issues. obesitylaw.com "Established by Walter Lindstrom in 1996, The Obesity Law & Advocacy Center is the first and premier advocacy practice devoted to representing the interests of morbidly obese persons in health care and discrimination matters. We work with people all over the country who suffer from this devastating disease who are seeking help with: Challenging insurance companies who deny access to medically necessary bariatric surgery and other types of health care for the diseases of obesity and morbid obesity through their internal appeals process or through external (independent) reviews." Walter helped our sweet JJ get her surgery last year [after a 7 year battle with TRC]. Hope this helps someone out there!!
   — Egyptianeyesdiva

May 25, 2005
Donna, I am so sorry you are having to deal with this. I too am insured through Aetna (the Gaylord Entertainment insurer) and of course any type of WLS was on their exclusion list. I spoke to several people at Aetna and there was no way they said that Gaylord would approve it even though it was a medical necessity case. They were very strict on all their policies and I just don't have time to legally fight it so I have decided to go through Medicare and I will have to pay 20%.
   — Pamela B.

May 25, 2005
There are a couple of websites that may help if it is truly a medical necessity... obesitylaw.com/index.htm wlshelp.com
   — David B.

May 25, 2005
Please go on my profile and read my journey. I used Walter Lindstrom (actually his wife Kelly) from Obesitylaw.com and they rocked! I'm now five months out from surgery and down 71 pounds! (RNY LAP 12/17/04), please email me with any questions and good luck!
   — jenniferw