Question:
Does anyone know what I need to do next?

I haven't received the official letter of denial, but the person that I spoke with was not concerned. After telling me that my company had a written exclusion on the surgery and that if I just ate a balanced diet and worked out more often, then I wouldn't have to worry about the surgery. After asking to speak to the supervisor the call was miraculously disconnected. I went to their web site and found that they list the surgery as: The following services are not covered: Cosmetic Procedures - Weight loss programs whether or not they are under medical supervision. Weight loss programs for medical reasons are also excluded. Reading further I found that if you had a breast implant (which has nothing to do with me) and it ruptured then your SOL. - Replacement of an existing breast implant if the earlier breast implant was performed as a Cosmetic Procedure. NOTE: Replacement of an existing breast implant is considered reconstructive if the initial breast implant followed mastectomy. I can't understand that being 415 lbs with a BMI of 49.2 is a cosmetic issue. My next question is if the IRS list "Obesity as a Disease" and The cost of participation in a weight-loss program as a treatment for the disease of obesity is an amount paid for medical care which is reimbursable, how could the insurance company not be willing to pay for the surgery if they can re-coop the money on their on taxes?    — Eric S. (posted on May 26, 2003)

May 26, 2003
In my opinion I would appeal as not covering Weight Loss Programs is not the same as a medical procedure - surgery. Assuming you have some good (or should I say bad) co-morbs I would pursue it. Get a good letter from your PCP and/or surgeon indicating your medical necessity for this surgery. You are on the bubble to becoming Super Morbidly Obese (50 BMI) and that is nothing to sneeze at. Not picking on you here just pointing out the truth. I started at 63.8 BMI. <p>My insurance won't cover any treatment for weight loss unless you are at least morbidly obese and meet medical necessity. Since your plan doesn't address morbid obesity and WLS I would go for it. You will need a strongly worded letter including details on what diet attempts you have made over the years and lbs lost etc. My surgeon had some reference in my letter in relation to making me try another diet. It said something to the effect that requiring me to try another diet is in effect asking someone to do another proven ineffective treatment just so they can have a proven effective treatment. In other words it's a waste of time to ask for another diet. Statistics prove that diets are not a long term solution for the morbidly and super morbidly obese person. Good Luck!
   — zoedogcbr

May 26, 2003
I would appeal and put in everything that is wrong with you. Have your surgeon, your PCP and any other doctor you have seen write a letter explaining why you NEED this surgery. The wording on your insurance policy does not sound like it is worded very strong. Sounds to me like you might have a good shot at an appeal. Good Luck!
   — TheresaC