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I think it just depends on what requirements are written into your health care plan. It seems like the insurance company decides, but your employer controls some of the requirements based on what kind of plan they select for their employees. So even though I'm sure there are many surgeons who will do surgery if you're under 21, you're kind of at the mercy of the requirements of your own specific insurance plan.
Based on what I have learned in my insurance quest, once thing**** the independent review process, you're evaluated on the basis of medical necessity, not insurance coverage. My recommendation is to invest the time in talking to someone experienced in the area and see what they say. From what I understand, it's a tough road to go, but I think some people have overcome their exclusions.
Sleeved 6/12/13 - 100 pounds lost to get to goal!
I don't think that it is worth fighting, although if you do fight it, the worst that can happen is that they say no (and you spend time and possibly money). If the employer excluded it, it is excluded, and the insurance company has no obligation to cover it. Look to see if there are state laws regarding whether it must be included. Alternatively, you can seek out an attorney who specializes in this to see if you have any rights.
Good luck!
HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"
M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)
Anyone ever fight a written exclusion to cover WLS? It is not and employer based exclusion just a general policy one.
Is it even worth fighting it? Could it be appealed and over turned with enough proof of medical necessity?
Thanks in advance.
HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"
M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)
You should see if you can make payments or if you are not set on that surgeon, see if there is another in your area who works better. Not all offices charge that high of a program fee.
I am going to my first seminar on Saturday. I received paperwork from the office that is holding the seminar. If you chose to have surgery with them there is an additional $1250.00 that you have to pay for office visits and to see their behaviorist. They said it cannot be charged off to your insurance. Has anyone heard of this before?
They may have you on the 1st issue, too. Make an appt today to have a weigh-in on March 14. That way, you can show 90 days (3 months) of monitored weight loss/weigh ins. Right now, since you started on December 14, then January 14 counts as a first full month, February 14 counts as a 2nd full month, and March 14 will count as your 3rd full month.
Also, are you sure that your psych eval results were included in the packet? If not, get it in now. Same with your PCP.
Hopefully, with your BMI, they might let you go through without technically meeting all the requirements. But, honestly, I think they will initially deny you until you meet all their steps. So, that means resubmitting right after March 14.
Good luck!!! I know it is so frustrating!
HW: 274 | SW: 232 | CW: 137 | Goal: 145 (ticker includes a 42 pound loss pre-op) | Height: 5'4"
M1: -24 (205) | M2: -14 (191) | M3: -11 (180) | M4: -7 (173) | M5: -7 (166) | M6: -8 (158) | M7: -11 (147) | M8: -2 (145) | M9: -3 (142) | M10: -2 (140) | M11: -4 (136) | M12: -2 (134) | M13: -0 (134) | M14: -3 (131) | M15: +4 (135) | M16: +2 (137)
Hello All,
This is my first post. I just joined ObesityHelp and I am thrilled to be here!
I am trying to get approval from CIGNA for a VSG. I am 22. My BMI is 57 and I've met all of the requirements by CIGNA. I did 3 months of weighing in starting on December 14, 2012. My second weigh in was January 21, 2013 and my third was February 22, 2013. I lost 9 lbs overall. I gained a little over Christmas and in January, but lost that weight +9 additional pounds. Anyway, I also was being monitored by a dietitian, and a psychologist. I had a psych eval and passed with flying colors. I had also initially talked to my PCP on October 25, 2012 about wanting to get the Sleeve and about what my options were and she was very supportive. So on February 22, 2012, my paperwork was faxed to CIGNA.
I have been calling them every single day (sometimes 2X a day) to follow up on the status of my claim. Well yesterday, March 1, 2013, I found out that my claim was being passed on to a medical examiner for revision. So that means the CIGNA nurse denied it initially. The basis for her denial was this:
-I did not meet the 3 month weight loss monitored program
-I did not have a psych evaluation
-I did not have a letter from another doctor giving me approval for the surgery such as my PCP
So, I know the first 2 reasons are not valid and can easily be sorted out. The third reason is completely my fault. I thought the weight loss center would contact my PCP to get the letter for the packet before they submitted the request to the insurance...they did NOT do that. I'm freaking out here. I was told the medical examiner would review my claim on Monday or Tuesday of this next week. I know that if I do not have the letter from my PCP that my claim will be denied. If I can manage to get the letter to CIGNA via fax from my PCP then there's hope, but I'm scared that it won't make it to CIGNA before my claim is denied.
I was wanting to get this surgery on my spring break because I'm a teacher and that would give me plenty of time to recover before school starts back up.
Is there anyone out there can give me some advice? I really need it.
Best,
Lindsay
Hockeymom87 · 0 replies · 728 views
