Question:
My enployer is under a self-funded plan governed by ERISA.

Is this a difficult plan to get WLS?Who makes the final decision on aproval or denial?(ERISA or my employer)    — Jeff M. (posted on March 27, 2002)

March 27, 2002
hmmm not sure about if its a difficult plan to use or not but, i can tell you that with my insurance which is also self funded, that when it came time to do the third appeal that i had to go before the personnel committee. I work for a county. hope i could help you in some way.debbie
   — deborah D.

March 27, 2002
Definitely your employer! I went through this process. You first have to go through the process of getting your doctor to submit the request and then getting the denial from the insurance company. Then you should take it to your employee benefits office and ask them to handle it. You might want to add some information such as ADA and so forth - just to add to your justification. Hope this helps you somewhat. Sharon Robinson
   — Sharon R.

March 27, 2002
Just as an FYI...ERISA doesn't make any decisions. ERISA is a federal act created in 1974 that basically sets the minumum standards required of all pension and health benefit plans in private industry, and provides protection for those of us enrolled in one of these plans. Employers can extend greater coverage than that required by ERISA...because, although ERISA is a good and essential thing - quite frankly, when they say minimum, they mean minimum. Anyway...I agree with a previous poster. Self funded plan? If you get denied by the insurance company, take it up with your company directly. Best of luck to you!
   — PaulaM

March 27, 2002
HAve you checked your plan documents to see if WLS is listed as covered or excluded? I too work for a Co. that carries self-funded benefits. I was very luck in that our plan specifically covers "surgery for the treatment of morbid obesity". When it came time to start the approval process, it took less then 24 hours for approval through our administrator. If you don't have your plan documents, you should be able to obtain them from your HR/Benefits Department. In the end, your employer has the final say in whether or not WLS would be covered. Best of luck.
   — Rosario T.

July 8, 2002
I'm under self-funded state of TX plan also governed by ERISA...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.

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