Insurance Exclusion, is it worth the fight?

RKLC2002
on 12/5/10 4:48 pm - Omaha, NE
DS on 10/14/11 with

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,
Renee

Jersey Girl
on 12/5/10 5:08 pm
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 5:28 pm
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.
RKLC2002
on 12/5/10 6:09 pm - Omaha, NE
DS on 10/14/11 with
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 6:16 pm
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            
nightowl
on 12/5/10 9:49 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 6:36 pm
If it's specifically excluded it sounds like self-pay is the best option.  That was my situation. 
Renee2007
on 12/5/10 7:20 pm - 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.

Renee
 My DS   
SW/263  CW/136 GW/150



thompson13x
on 12/5/10 8:56 pm - Fort Worth, TX
I work for a company that is Self insured as well, yet uses UHC as its plan administrator. Our insurance had an explicit written exclusion that specifically mentioned that it would not cover any WLS. I knew this going into it and informed my surgeon of such and the staff there started drawing up the appeal paper work. I was able to add a letter of recommendation from my gastro, neuro, and PCP, and was approved on my first appeal.

The reality was that the appeals board that handles our company, was able to clearly see and quickly justify that the 20k or so for the DS was going to be less expensive over all than the possible long term health issues I was facing in the near/immediate future.

Never say never, Appeal away, what is the worst they could tell you, NO???

                      HW: 372lbs.   SW: 358lbs.  Goal: 180lbs. CW: 165ish          
                    Pants: 54 to 32 - Shirts: 4x to Med - I My DS!