Insurance

Can someone tell me if you have any options when your insurance policy has an exclusion for surgery? I really need to have the surgery, but our family lives from paycheck to paycheck. Any advice would be greatly appreciated.

Unfortunately the only other option is self pay, I'm in a similar situation. My lap band has been a total failure and I really need to revise to a better surgery but my insurance has a bariatric exclusion and there is no way I know of to get around it. Some people go to Mexico since surgery is much less expensive there but it is still a self pay situation. Wish I had better news for you.

Thank you for answering me. I am going to talk with my doctor and see if there is anything he can do.

 Well, my insurance excludes bariatrics .. At least the coverage my employer carries.

However, they seem to set aside some funds and approve procedures when highly medically necessary.

I have a co worker who had multiple comorbidities and they paid for his surgery.
They did not pay for mine.

It does not hurt to ask and get your doc to advocate on your behalf.

Can you get Medicaid? If need be, as a last resort, can you cut back your hours at work to qualify for Medicaid, just for awhile? How about a bank loan? I know some people go to Mexico for the procedure, as it's half the cost there.

My insurance has an exclusion for any weight loss surgery. However, it is covered under my husband's plan. So, I am waiting for his open enrollment period and hopefully hopping over there.

What are the reasons for the exlucsions. My understanding is that a certain level of comorbidities increase eligibility. I had a BMI of 50, sleep apnea, and hypertension. Type 2 diabetes can be a good one too. I imagine that any insurance company can see the benefit of a $25,000 bariatric surgery being the smarter decision over a lifetime of diabetic meds and complications.

I know this probably isn't the best time to suggest this, but what are your options when it comes to switching employers? I knew a woman who got Gastric Bypass when she was unemployed by paying out of pocket for COBRA. COBRA is expensive, but If it costs $3,000 for say 4 months of coverage, it's a small amount compared to paying for the whole surgery out of pocket.

Does your employer have an open enrollment where you can switch plans? Mine has 3 different plans, but only 1 covers bariatric surgery. And surprisingly it was the least expensive plan. If you are married, does your spouse work, and if so do why insure you through their employer? Double coverage has been a God send in my case, I've seen very few bills. Though, the issue is that your primary insurance still has to cover the surgery for the secondary to pick up the remainder.

There are medical loans out there. But I don't like loans in general. On the plus side, they can't repo your stomach.

Assuming you can finagal an approval, don't take a less invasive procedure like lap-band. I'd suggest having RNY or DS because if you're insurance is already stubborn, they will not likely pay for a revision later if you need it. My primary has a $15,000 lifetime maximum on bariatric procedures, so I flipped my decision from VSG to RNY because I wanted to avoid having to readdress this in the future. It's a personal choice, so that's just a suggestion.

Can you post the exact wording of the exclusion here? There might be a loophole, if, for example, it says they don't cover treatment for obesity---soometimes, if you read further, they do cover treatment for morbid obesity, which is a different medical diagnosis.

And I agree with the poster who suggested you look at the DS. The DS has the very best long-term, maintained weight-loss stats for patients of any size, but this is especially true for those of us with a BMI greater than 50. It's also the very best at resolving or preventing co-morbs like diabetes and high cholesterol.

This is what I got sent in an email from the insurance company.

For all Medical Benefits shown in the Schedule of Benefits, a charge for the following is not covered:

(ff) Obesity. Weight reduction programs or other treatment for obesity, including but not limited to, surgery of any type for obesity or morbid obesity or complications resulting from surgery or for removal of fat or skin following weight loss regardless of whether the Plan Participant’s treating physician determines that the treatment is medically necessary. In addition, charges for services at a weight reduction clinic, health spa, health fitness facility, or similar facility are excluded.


I appreciate all the advice. I am not giving up!

You certainly have rights to appeal any denial, including one based on an exclusion.  It would be a mistake to simply give up without exploring all of your options.  More details concerning your rights and options are here:
wlsappeals.com/common-bariatric-denials/contract-exclusions/

Good luck!

This is what I got sent in an email from the insurance company.

For all Medical Benefits shown in the Schedule of Benefits, a charge for the following is not covered:

 (ff) Obesity. Weight reduction programs or other treatment for obesity, including but not limited to, surgery of any type for obesity or morbid obesity or complications resulting from surgery or for removal of fat or skin following weight loss regardless of whether the Plan Participant’s treating physician determines that the treatment is medically necessary. In addition, charges for services at a weight reduction clinic, health spa, health fitness facility, or similar facility are excluded.


I appreciate all the advice. I am not giving up!