Question:
I am having a hard time getting my insurance to approve this surgery. I have written
and asked for pre-authorization and was sent a letter stating it was an exclusion in the contract. My contract states "treatment of obesity is excluded". I then appealed and wrote a 17 page appeal letter explaining the difference between obesity and morbid obesity and outlining all my co-morbidities, etc. It was very thourough and they denied again saying, sorry, its an exclusion in the contract and obesity is obesity. So now, I don't know what to do. Is it worth fighting? Has anyone ever won on appeal with an exclusion like this if they hired Walter? Need help!! Surgery is scheduled for March 23rd. — Tracy P. (posted on March 11, 2001)
March 11, 2001
I just sent you personal response because I can't cut and paste into the
response here. Anyway I forgot to ask - Have you had your doctor write a
letter of medical necessity? Have you contacted a surgeon - they are very
good at writing letters for precertification.
— K T.
March 12, 2001
I was wondering.. do you have physician support and did any medical Dr
request your authorization?
— Dawn R.
March 12, 2001
Sorry to tell you....but I did EVERYTHING and the companies(I have double
coverage)stuck to their guns..even Walter told me the chances were really
slim with my insurance companies. I ended up being a selfpay because this
surgery was that important to me...I have decided not to dwell on it and
that the $18,640.00 that I spent 8 weeks ago was well worth it. I fought
the insurance companies for a year and during that time I saved my butt
off(excuse the pun) in case I couldn't get it covered. It still iriates me
because it looks as if the majority of the people on this site has the
surgeries covered. However, being a self pay I was able to choose what
surgeon I wanted across this country and what procedure I wanted. I had a
LAP RNY in GA(I'm in WA) with who I felt was the best LAP surgeon in the
country and spent a lot less than the other surgeries I see on this site. I
guess my point is Good Luck but don't be discouraged if you can't get it
covered. If you really want the surgery be patient and find a way to
finance it.
— Debora H.
March 12, 2001
In your profile, it says you are having a DS. Are you sure the insurance
company isn't denying you based on that? Have you tried getting approval
for a Roux-en-y? In my research, I've found that a lot of companies won't
approve DS because it's too new.
— PT LawMom
March 17, 2001
Since I work at a third party administrator for health insurance I am
familiar with the term "treatment for obesity not covered."
I agree with Deborah Hadley and Walter. There is very little chance that
insurance company will cover the surgery because of the exclusion. I also
know this from personal experience as my insurance at work has the same
exact exclusion and I was denied. I went on my husbands insurance and got
approved. Perhaps you have that option.
— Ginny N.
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