Question:
Has anyone dealt with a DENIAL based on an EXCLUSION to a policy by the employer?

I have a surgery date and just found out I was denied b/c of an exlusion in my husband ins. policy (BC/BS of MA) by the company he works for. My Dr.'s office says I should write an appeal letter. Has anyone been successful with this type of appeal? The exlusion states "no coverage for treatment of obesity or weight loss". HELP! Thanks!    — [Anonymous] (posted on August 9, 2001)

August 9, 2001
My Employer would NOT change their policy. I wrote 2 appeal letters. They kept quoting the same line Weight loss not covered even if medically necesary. I talked w/ Walter and was about to use him when I got a new job and they have Aetna, and it's covered!!!! Good luck to you.
   — Cindee A.

August 9, 2001
I had an exclusion with my employer which has Cigna HMO. I was told by New Start to contact my benefits department which I did. The benefits rep asked for a DC9 letter from my surgeon and then they would contact Cigna. I am not sure what exactly they sent Cigna but they accepted it, though they then denied me because of no doctor supervised weight loss attempts. I then began a diet with my pcp which I have been on for three months. I sent in a second appeal letter and was approved today.
   — POOBEAR

August 13, 2001
Hello, I wrote a long letter to my HR department. I asked them to help me get approved and they did. I will share the letter with you if you post your email address. :)
   — [Anonymous]

November 7, 2001
I don't know if the anonomous person that posted before is still hangiong around, but I would be very interested in seeing his/her letter to HR. Thanks!
   — Toni C.

May 13, 2002
Anom. please email me your letter I would really appreciate it cause right now I'm working on my 2nd appeal letter.
   — Victoria T.

July 8, 2002
I've been working w/the group at COMPASS, used to be IMAGES, and they've confirmed that the BCBS-TX exclusion isn't iron-clad because the medically necessary clause has worked, and they're working with me to get approval based on that. I know there are several who've tried to get past this based on a LOMN and were denied, but my case-worker lady seems confident based on the information provided by her contact at BCBSTX. See below: Dear Lynda, I spoke with Lettie at Blue Cross today and was told that they will consider this surgery if medically necessary, however as you have an HMO they will not allow you to go out of network. I noticed that you stated that you will roll over to PPO in September. I would suggest we wait until after September 1 to submit the letter of medical necessity for approval as they will certainly deny it due to being out of network. Please let me know how you would like to proceed and thanks for letting us know that they will consider this procedure. Up to now we have always been told that this was a "definite exclusion" on this policy even with medical necessity. Thanks and I look forward to hearing from you. Sheridan at Compass GOOD LUCK EVERYONE!! :)
   — Lynda L.

Click Here to Return