Question:
Can you get insurance approval like this?

Bad news is I found out that there is a WLS exclusion in my policy. Called the insurance company for more clarification. One of the reps (yes, I documented the call) told me that if the surgery was medically necessary to cure or correct other problems like diabeties, sleep apnea, etc. the claim would probably be approved since I was being treated for something other than obesity. Has anyone had any luck getting approved this way??? Is it even possible to get approval using other medical problems as the reason for your surgery???    — helloitsme (posted on January 10, 2006)

January 10, 2006
Yes. In fact most people get their insurance approval through this method. very few insurance companies, although there are some, will approve due to BMI only. There needs to be a medical necessity as well. Usually something like diabetes, sleep apnea, heart disease, high blood pressure, high cholosterol, high triglicyrides, arthritis or combinations of these. Each insurance company has their own criteria. Each state has their own laws governing what is and is not covered. Good luck, Michelle "Pookie" Engelmann
   — Michelle E.

January 10, 2006
Definitely. most insurance companies dont cover just for the weight loss alone, they want to know that your weight problem is contributing to other problems.. start a list of everything you can think of that affected by your weight.. joint pain, knees, back pain, high blood pressure, even acne can be a cause.. Make sure your doctor notes everything for you.. get a ltter from him listing your ailments.. that will help.. Good luck!!!
   — April

January 10, 2006
I had this happen to me..you can look at it two way...the first being if you have any comobities(diabetes, sleep apnea) then they will almost immediatley approve you(I have BCBS of GA and the rep I spoke with said that they kinda weight out the costs...I was diabetic and had high bp etc and it was cheaper for them to pay for surgery then to keep paying for treatments of the other problems) if you have no comorbities then pray that your doctor can prove that it is medically necessary...if you have been with your dr. for several years he/she should have it all documented the weight gain over a period of time. I am not sure of the insurance that you have, but with BCBS(from read other people who have it they pretty much have the same concensus in every state) you need a 10 year weight diet history and a weight history...they want to know what diets or other things you have tried to do to lose weight...list even the things that you may think are insignificant....you will also need a letter of medical necessity and medical clearance(get both from your PCP...but they have to be TWO DIFFERENT LETTERS...otherwise it will delay your claim)...good luck...you'll be on the losers side before you know it....Erica :)
   — dillaq

January 10, 2006
My former insurance policy contained a WLS 'exclusion' which basically meant no surgery under any circumstances. I had a surgeon to tell me that in this situation approval was damn near impossible to obtain. I changed insurance companies. Thanks all for being here and for allowing me the opportunity to be involved. I'm on this journey pretty much on my own. I need the support. Thanks!!!!
   — cooky808

January 10, 2006
Yes. If you are being treated for those conditions, get your doctor to write a letter stating so.
   — Novashannon

January 11, 2006
Yes, a lot of people are approved this way -- they are call co-morbidities. A friend of mine wants to have the surgery done, however, her company has an exclusion and I reminder her of these two little words "medically necessary."
   — the7thdean

January 12, 2006
I am proof of it not only was my BMI high but I also have many other health problems. On my letter from my PCP she also stated that I did many different diets in the past as well as working out and being on a diet 800-1200 calories a day. She also stated with a number of comorbidities hypertension, asthma, NASH, sleep apnea, lumbar stenosis and bilateral knee DJD, and interstitial cystitis that they should all improve with a dramatic weight loss after gastric bypass surgery. And I was approved within 8 hours after the paperwork was faxed to the insurance company gateway. Best of luck.
   — jamierankin

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