Question:
Anyone know why some people get approved...
and others get denied using the exact same insurance company in the same state? I realize there are different issues at hand, such as BMI's, comorbids, etc. But one would think that if its a policy exclusion, ALL would be denied, but I've seen evidence contrary to this. Is it really who has the most and best documentation, persistence and knowledge of how the "system" works? Do you think that being tenacious and showing the insurance company that you will fight and not go away helps in any way, or just wasting breath? — [Anonymous] (posted on August 30, 2000)
August 30, 2000
It depends on your employer. They are the ones who make the exclusions,
and since it costs more to cover more... well, you know. Just because
there is an exclusion does not mean that it will never be covered. There
are ways around some exclusions. The policy may exclude treatment for
obesity, but not exclude treatment for morbid obesity. They may exclude
treatment for obesity, and morbid obesity, but if you have medical
neccessity & co-morbidities, sometimes they will approve the surgery
anyway. I hope this helps a little. Good Luck!
— Shelly T.
August 30, 2000
AMEN Shelly. Absolutely great information. Depending on the language of
your policy you may have to approach the WLS surgery from a different
angle. As Shelly said you may have to go about it not for weight loss at
all and the doc will have to say it is primary treatment for one of your
comorbids. In other words the WLS is treatment for Diabetes or Reflux
disease. The power is in the exact wording of the exclusion and further
clues lie in the exact words of the denial. If you do not have a copy of
the policy and it's exclusions in detail you need to have one to help you
with your fight. You need to know how to address this in Round 2. Best of
Luck and Hugs
— JennyLynn A.
August 30, 2000
I was turned down the first time I applied because it did not show that it
was medically necessary. In my appeal it listed all my comorbs and effects
of the surgery on them and I was approved. Sometimes I think the companies
wait to see if we will fight for what we want. Don't give up.
Donna WV
— Donna A.
September 9, 2000
— mary N.
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