Question:
Exclusions?
This is exactly what my insurance manual states: Weight Loss: services and supplies to treat obesity, weight loss or dietary control even if they are part of the treatment plan for another sickness. But the Plan may cover some services and supplies for weight loss if the Claims Administrator determines that these services and supplies are Medically Necessary based on its evaluation of your body mas index (BMI) and health status. So my Questions is, does this mean that the will cover Weight Loss surgery? Has anyone else been approved with this as part of your policy? Thanks for any input. Joanne — Joanne B. (posted on April 30, 2002)
April 30, 2002
After reviewing the information that you posted: I feel that they are not
stating that surgery for morbid obesity for a Gastric Bypass is an
Exclusion ; they are stating that it needs to be proven medically
necessary. Which should be done by your surgeons office. They should do a
Pre-Determinatiion.
Thanks,
Beth
— Beth M.
April 30, 2002
It is my opinion that your insurance can choose to cover it IF it is
medically necessary . In addition to a BMI over 40 you may have to show you
suufer from diabetes, HBP, etc. You are fortunate your insurance provides a
window of opportunity for surgery approval.
— Linda M.
April 30, 2002
This is a very vague exclusion. However it does not state that surgical
treatment is not covered. And it also states that they will cover obesity
treatment if they feel you meet certain criteria. I would view this as a
positive had it been my policy.
— RebeccaP
April 30, 2002
I just asked a similar question last week! Mine was almost worded the
same. Just to double check, I emailed the customer service at Aetna. THey
said WLS is covered as long as it is approved prior. I think as long as
your surgeon submits ahead of time, you'll be fine. Check with the
insurance company though.
— emilyfink
April 30, 2002
My interpretation is that if you have serious weight related health
problems, it should cover WLS. Sounds like with "BMI and Health
Status", they are open to covering WLS if you meet the criteria.
I see from your profile that your BMI is 39, which will be a tough sell to
get WLS, because the criteria used is usually over 40, but will cover over
35 with severe weight related health problems. Bet you never thought you
might be to thin?
But give it a try and submit it. Like I said, it will most likely depend on
how serious your comorbidities are.
— Dell H.
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