Appealing my weird denial

Hey all,

So I posted last week that my insurance company denied RNY surgery claiming that I did not show an "urgent" need for the procedure over the phone. I've asked them to email me the specifics of the denail, and what they wrote was: 

"No benefits will be paid for:Coverage was denied for surgery as the surgical procedure was deemed elective treatment.  As there is no specific medical urgency to have the surgery, the policy would not cover the procedure."

I am definitely going to fight this. The NIH guidelines say nothing about urgency. After all, if they did, Kaiser et al. wouldn't be able to have 10% loss or nutrition class pre-requirements!

In terms of coverage, the only applicable exerpt I can see in my coverage booklet was: 

"No benefits will be paid for:

...

Elective surgery (except as provided by the policy). Any elective treatment, surgery, health treatment, or examination (a) deemed by us to be experimental; and (b) not recognized and generally accepted medical practices in the United States."

I'm not a law student, but the verbage in my coverage booklet describing medical necessity says nothing about urgency, and there is no specific exclusion policy for WLS.

I've contacted obesity law, but I'm wondering if anyone has any examples of appeals for denails based on assessing the surgery as "elective" for reasons other than ?


Thanks in advance,
Somayeh

 Ugh! Insurance issues! A battle that seems to have no end. My insurance tried to deny me at the very end, but my bulldog of a surgeon got everything corrected.

I know for me there were a number of reasons I could have been denied, or approved easier. Most of it centers around other health issues. If obesity is the only health problem, and you are other wise in excellent health, I suppose they could argue that the surgery is not necessary. I had a long family history of obesity related health issues, along with an auto-immune disorder that would be helped by loss of weight. Not to mention my on-going reproductive issues. Ugh. 

I think what they may be trying to say is if you have any other obesity related disorders, they don't consider them life threatening, and therefore they believe the surgery to be unecessary. Keep in mind, they are always looking for reasons to say no.

Your job... find reasons to make them say yes!

Don't give up, put up a fight. My surgeon and I fought tooth and nail, and it seems the squeaky wheel does get the oil! Find out from them just what would make it "urgent." Keep pushing buttons and asking questions.

What is your BMI and do you have co-morbidities?  Those are the things they look for to approve.  Otherwise, if your BMI isn't high enough and you don't have other health related issues, you are "electing" and it isn't "medically necessary"

Don't give up! Keep appealing! 

I think you need to go back to your policy requirements. It sounds like you have Kaiser but you haven't said so. If you want some help, you need to give some specifics. From what I've gleaned from your blog, you've had some thyroid problems in the past. I'm not sure whether you have had any kind of weight loss surgery but I know you have lost a lot of weight on your own. I commend you for losing so much weight. I assume you are just over the BMI at 40. This is usually the number used where you don't need additional co-morbid diseases. Correct me if I'm wrong, I believe you are currently overseas as a student with no clear date on when you will be returning to the States. Do you have your own insurance or is it through someone else?



I agree that if you meet the requirements it does not seem likely that they can deny your claim for benefits because of urgency unless there is something in your policy that states that because you are overseas.
There are a lot of people here who have been able to appeal denials but they cannot translate their experience to help you if you don't give a clearer picture of your situation.


Please know that I am trying to help you. I understand your struggles with your weight and I feel your pain. I will help you any way I can but I need more information. It you want to send me a private message please do so. I commend you for reaching out for help.

Thanks for the replies, all.I'd like to clarify a few of the things I left out of my original post. All your input is VERY helpful =)

I don't have Kaiser, although at this point I almost wish I did. I don't know who the actual insurance underwriter is, because it's a travel assistance insurance through my university's study abroad program. I've had to go through a "benefits coordinator" type company as a go-between betwix myself and the insurer.

My insurance booklet verbage is incredibly vague. There are two sections that for me seem contradictory, or at least open the door to the appeal. They called it elective because it wasn't urgent, but as I stated before, they say no benefits will be paid for:

"Elective surgery (except as provided by the policy). Any elective treatment, surgery, health treatment, or examination (a) deemed by us to be experimental; and (b) not recognized and generally accepted medical practices in the United States."

The other direct quote that I think applies here is their definition for the term "Medical Necessity" which is:

"“Medically Necessary" means a treatment, service, or supply that is: 1) required to treat an Injury or Sickness; 2) prescribed or ordered by a Doctor or furnished by a Hospital; 3) performed in the least costly setting required by the covered person’s condition; and 4) consistent with the medical and surgical practices prevailing in the area for treatment of the condition at the time rendered. Purchasing or renting 1) air conditioners, 2) air purifiers, 3) motorized transportation equipment, 4) escalators or elevators in private homes, 5) eyeglass frames or lenses, 6) hearing aids, 7) swimming pools or supplies for them, and 8) general exercise equipment is not Medically Necessary. A service or supply may not be Medically Necessary if a less intensive or more appropriate diagnostic or treatment alternative could have been used. We may, at our discretion, consider the cost of the alternative to be the Covered Expense.  "



I think the main sticking point is going to be whethere the "elective surgery" exemption is for all elective surgeries, or for the ones that fit the (a) and (b) categories above. It looks to me like it's the latter. If so, I have a case for appeal. 

I should point out that the rep on the phone told me that it doesn't necessarily mean they're calling it "not medically necessary," just that I didn't show a need for urgency. 

My BMI is: 41.5. My comorbidities are:
 -High cholesterol
-Metabolic syndrome
-Polycystic ovarian syndrome
-Hypothyroidism
-Chondromalacia patellae
-Asthma
-Depression

Thanks for your time everyone,
Somayeh  

I think your problem is that you have travel insurance....which isn't really medical insurance in the traditional sense.  Most travel insurance policies (like emergency insurance policies) only cover life threatening medical conditions that have to be performed immediately or will result in the lose of life.  Using that definition, RNY doesn't fit the bill.

For instance, needing surgery after a car accident to repair a ruptured spleen....or needing an emergency appendectomy.  I think they are denying your claim because having RNY is a procedure that you can have done in the US when you return.  There is no urgent medical need for it to be performed in your host country.

If you are in college, you should qualify for coverage under your parents insurance, which might better than trying to get the procedure covered by travel insurance.

Hillery is right - if you are a student and under 26 you can qualify for coverage under your parent's insurance. You should look into this; it might very well turn things around for you.