Exclusion and California Commission on Insurance

  I have been doing a lot of research on bariatiric  surgery, insurance and all aspects of it.  I am really a research geek so to speak.  lol.  Any way I had sent an email to the California Commision on Insurance  and recieved a call from them yesterday.  My email was inquiring the definintion of the term "delivered in"  as I live in Maryland and there is a state law that requires group health insurance that is "delivered in" the state of Maryland to cover wls if  certain criteria is met including the National Institute of Health criteria. (of which i meet) .  At first the lady was going to send me a letter with a simple vague definition: something told her to call me instead and get the full story.  I explained that my current health insurance is not self funded and they have locations both nationally and internationally and have more than 500 employees. ( which makes a difference).  They are sending me paper work and they want my whole story and say that If i need an independent medical review that there is a good chance of haveing a denial overturned.  She also stated that since the exclusion is listed certificate of coverage that my health insurnace company is the one that placed the exclusion on my employer.  I will keep you all updated as to the progress.  I am so glad I took Rens advice and came to this site. 
Oh btw my health insurance is United Health Care Choice Plus.

I hope this helps others

Hi There,
I also have the same insurance but I live in Texas. I believe my company has an exclusion and was wondering how I could get around it. I already have a lapband (selfpay-Mexico)but was wanting a revision to a sleeve. When I got my lapband I didn't have insurance. Now that I do, and I have gained back weight, I really want to try the sleeve -VSG. Please contact me at [email protected] if you have any more info. Thanks!

Tracey:

Hi, as you know I am a research NUT.  I think that I may have found something that may help us both with the exclusion on wls and United Health Care.


Look up the following information
Cal. Admin. Code tit. 10, § 2699.6203

a) Health benefits plans offered under this program shall exclude the following benefits:

(13) Treatment of obesity by medical and surgical means, except for treatment of morbid obesity. In no instance shall treatment for morbid obesity be provided primarily for cosmetic reasons.

The Key words here are except and primarily for cosmetic reasons.

You and I both know that the reason for the surgery is not cosmetic
and if you have co morbidities like me then I do not see how they can deny treatment. 

Please let know if this helps you.

Also I am trying to get letters of medical necessity from all or most of the doctors that I have been to and writing a detailed letter with ICD-9 codes ( diagnostic codes used for medical billing) and my personal
experience with obesity. 

I have two more sessions with the nutritionist before they submit my paper work. I will let you know how things go.

Please add me to your friends list.

Talk with you soon


Lori