Insurance Exclusion, is it worth the fight?

on 12/5/10 8:48 am - Omaha, NE

My company has any weight loss treatments or surgery as being excluded from our insurance plan.  If it's an 'exclusion', is it even worth filing an appeal?   It sounds like it's my companies decision to not cover the surgery to keep insurance expenses down for everyone.    Has anyone had success in appealing an exclusion?  If you were successful at appealing an exclusion, would you mind sending me a sample of the appeal letter?

I've decided that I will self-pay if I can't get insurance to cover it. 

Thank you,

Jersey Girl
on 12/5/10 9:08 am
Revision on 03/07/11 with

You can appeal to the insurance company, it will likely get denied.  The 2nd appeal is usually directly to your employer since it sounds like they are self-insured. 
Good Luck.    It's worth a try.

A l y s i a  (pronounced like A l i c i a)
Total weight loss since HW of 475:
Pounds lost since band revision to DS            
Emily F.
on 12/5/10 9:28 am
An appeal with get denied, you can call human resources and ask that they add weightloss surgery to their benefits the next time they change their policies. If its a big company they probably will say no. I've only heard one person doing that and it was a small mom and pop shop and they only did it for one year so she could get her surgery.

If they say no, you have your answer and join the ranks of self pay! Its worth it though.
on 12/5/10 10:09 am - Omaha, NE
Thanks.  That's what I thought as well.     We're self insured.  I pointed them to all of the wonderful info on the DS sties, but I have a feeling they never even brought it up.  I've asked for 3 years for them to consider it.   But, the good news is that they are adding more TMJ benefits... (SARCASM!!).   

This is the first time that I've felt confident that self-pay is going to be worth it for me.  I go to a seminar on Thursday, so I want to ask questions about the self pay.

I'm SOOO encouraged by the information on this board and the amount of information that everyone is willing to share.   I've been so very depressed lately that this is one thing that I'm actually getting happy about.   So, thank you all !!!!

Jersey Girl
on 12/5/10 10:16 am
Revision on 03/07/11 with

The self-insured companies kill me!!!  They add and substract benefits when it's convenient for them.  Usually some big wig in the company needs or wants something and it's magically covered, then gone! 

You're worth it!  And so is this surgery.  It will be the best investment in yourself you'll ever make!  And you won't have to deal with the insurance B.S. and play their waiting game!!!!

A l y s i a  (pronounced like A l i c i a)
Total weight loss since HW of 475:
Pounds lost since band revision to DS            
on 12/5/10 1:49 pm - Topeka, KS
I wanted to let you know right away that Dr. Anthone's self-pay rate is on the high end (I think around $40K), while there are other DS surgeons who also have good reputations who are more like $21K (Dr. Stewart in Texas and Dr. Peters in Pennsylvania), or even some thousands lower than that if you go out of the country.  That's a sad fact for someone who lives right in Dr. Anthone's area. 
There is also a Dr. Forse at Creighton now who does the DS, but I haven't heard what the self-pay rate would be there.
(deactivated member)
on 12/5/10 10:36 am
If it's specifically excluded it sounds like self-pay is the best option.  That was my situation. 
on 12/5/10 11:20 am - Central, FL
Our insurance excluded any and all forms of bariatric surgery. I was a self-pay and it was worth every dime I spent. ALL of my co-morbids disappeared. I take no prescription drugs....just lots of vitamins! Best decision I have ever made.

 My DS   
SW/263  CW/136 GW/150

on 7/29/15 8:57 am

Hi, I called my insurance today and they said wls is listed as an exclusion, so what should my next step be? I am just starting this process, calling the insurance was the only thing I've done so far just not sure where to go next.


on 2/22/18 10:38 pm

That' the same insurance my job has and the same exclusion. Can u tell me what clinic/doctor you used? I live in Fort Worth, TX also.

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