Question:
general exclusion not stating must be medical nessesity

My insurance exclusion(s)read "Surgical operations, procedure or treatment of obesity, except when Precertified by CHI" and "surgical operations, procedure or treatment of obesity, except when specifically approved by HMO." Insurance is Aetna Choice POS (in PA). Anyone know what this means? I'm confused when I call the insurance One person says nope not at all, the other says if it deemed a medical nessesity then we have to approve it, and yet another told me it doesn't have to be a medical nessesity be just preapproved and precertified. HELP!    — Mandy S. (posted on June 15, 2005)

June 15, 2005
The phrase 'medical nessesity' is a load of crap, unless the insurance company allows YOUR doctor to decide if it's a nessesity. Most insurance companies decide that for themselves. Sad, eh?<br><br>However, about your exclusion...I would view that as a possitive exclusion. You see, they are addressing WLS by stating that they will not pay for it for someone that is obese. You see, if you qualify for surgery, you are morbidly obese. :) This may be their way of restricting WLS to those that actually need it. <br>Usually when you call your insurance you don't get the brightest nut on the tree when it comes to looking up YOUR policy and it's exclusions. But that's just the opinion of someone that worked at an insurance company for several years. :P Anyhow, I would suggest that you submit for approval thru your surgeon and find out. I wouldn't view the above exclusion as a no. Rebecca
   — RebeccaP

June 16, 2005
Would you post the entire exclusion in its entirety on your profile without breaks because I am reading something different than the last poster. The last line that it says is "except when specifically approved by HMO", meaning to me that you have to have approval from the HMO - that is not a blanket exclusion. I would call the insurance company back and ask them to fax/send you the exact wording of it from THEIR policy booklet on coverage for this through your employer/insurance company. Also, ask them about the two different wordings ("precertified by CHI" and "approved by HMO") because they are contridictory. But again, this does not sound like a blanket exclusion to me. Good luck!
   — Nicki F.

June 16, 2005
My gut reaction is that it is covered if you push the issue and you meet the requirements. First of all you are not obese, you are Morbidly Obese which is a disease and a huge distinction! What this statement is saying, in my opinion, is that if you proceed without surgery without getting precertification from the proper place, it will not be covered. The fact that they are willing to precertify tells me it is covered in certain situations. I have not had a chance to read your profile so I do not know if you have other serious co-morbs or not. If you do, your PCP or surgeon needs to make sure they focus on that and use that as your medical necessity. If you only qualify by the 40 BMI it might be a harder struggle, but worth the fight. All I know is if this how the exclusion was written in my insurance booklet, I would not take no for an answer and go through whatever appeals were needed. <p>My coverage excluded surgery except in the case of morbid obesity and disease etiology. In other words just a 40 BMI would be a hard sell, but put anything significant with it and it would be approved. I had my approval very quickly. While I more than qualified with a 65 BMI, I also had significant sleep apnea along with some other less threatening co-morbs. <p>Good Luck and fight like it's your life in the balance, because it is!!
   — zoedogcbr

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