Help Please - Insurance Appeal

Hi All,

My insurance excludes VSG from its policy.  I am going to see the Dr. Tomorrow but his nurse called to let me know my insurance didn't cover this procedure.  Now people have had this covered by my insurance just very very few.  My case manager said it was people with GI problems, don't know what that means. lol.  So if the Dr. is telling me my insurance won't approve, how would I ever file an Appeal?  Thanks :)

If it's an non-covered procedure under your health insurance plan, there is nothing to appeal.  Non-covered means non-covered.  However, if your doctor can provide a reason for medical necessity, which means a medically necessary reason why you must have this surgery other than for weight loss, you may have grounds for an appeal.

Wish I could be more encouraging, however, I'd say your chances are probably about slim to none that you'd get this surgery approved without a very compelling medical reason. 

Omg! Thanks so much! one more question. If I want DS and it is a covered benefit, there is no surgeon in network tp do the procedure. Can I get it coveted out of network because there is no skilled in that type of surgery? My policy says you are able to do this if no one is qualified in network. But I'm not sure if that'd apply to a specific procedure? Thanks again! You've been a great help

If your policy will cover out-of-network for ANY WLS, then it must do so for ALL covered forms of WLS. So yes, start looking for a DS surgeon---you can find a list of vetted ones at www.dsfacts.com (And please, PLEASE don't use one that's NOT vetted!!!)

If there is no surgeon in your network, you should be able to obtain an insurance authorization to go outside you network.

There is an insurance forum around here some where. If you don't get enough help here, you should try there. I know that some people have templates of letters that they have used successfully in appeals that they will share with you.