My revision denied due to an exclusion... any experience with this?

KayLavonne
on 5/1/18 2:18 pm

Hello all,

My revision was denied due to an exclusion. All bariatric surgery is a non covered service. I want to appeal it, and I am wondering if it is even worth the effort. I could ask my HR to add it to our insurance package. However, I really was not planning to tell them about the surgery at all. We do not have an "official" HR person. I work for a non profit, and it is small. Has anyone had luck with appealing an insurance exclusion? Helpful advice only, as in ones with experience. I really do not want comments like "its standard for insurances" or other comments basically stating what I already know. I just really want to know if anyone had any success with this, or even failure.... Just dont wanna hear the ol "I told ya so".

On a much more positive note, I am in the non surgical weight loss program there. Its been two weeks and I have lost 4 pounds! I know it doesn't seem like much, but its a start! Consistency is key! If I can't get approved for the surgery, then I have no other choice but to work hard. These 4 pounds were extremely hard! But I did it!

hollykim
on 5/1/18 4:15 pm - Nashville, TN
Revision on 03/18/15
On May 1, 2018 at 9:18 PM Pacific Time, KayLavonne wrote:

Hello all,

My revision was denied due to an exclusion. All bariatric surgery is a non covered service. I want to appeal it, and I am wondering if it is even worth the effort. I could ask my HR to add it to our insurance package. However, I really was not planning to tell them about the surgery at all. We do not have an "official" HR person. I work for a non profit, and it is small. Has anyone had luck with appealing an insurance exclusion? Helpful advice only, as in ones with experience. I really do not want comments like "its standard for insurances" or other comments basically stating what I already know. I just really want to know if anyone had any success with this, or even failure.... Just dont wanna hear the ol "I told ya so".

On a much more positive note, I am in the non surgical weight loss program there. Its been two weeks and I have lost 4 pounds! I know it doesn't seem like much, but its a start! Consistency is key! If I can't get approved for the surgery, then I have no other choice but to work hard. These 4 pounds were extremely hard! But I did it!

I appeales my exclusion and had no luck.

it is excluded because the rider your employer can purchase from the insurance carrier is very expensive.

Most at small businesses won't buy the rider.

if the insurance co is not going to cover a surgery that the rider hasn't been purchased for.

Have you considered self pay on MX? That is what I did and my experience was great.

 


          

 

KayLavonne
on 5/2/18 3:21 pm

Mx is my last resort. But my sis in law has gotten her exclusion overturned! However, she is a first timer, not a revision. So I will at least try. And if not, it will be Mx in a year.

Grim_Traveller
on 5/9/18 11:10 am
RNY on 08/21/12

Denials get overturned all the time. But an exclusion means there is no coverage at all, and I've never seen that overturned.

It's like filing a car insurance claim for something that isn't covered. If someone didn't pay for coverage, the insurance company can't be made to pay.

6'3" tall, male. Maintaining a loss of 280 pounds.

Highest weight was 475. Consult weight 04/12 was 411. RNY on 08/21/12 at 359 lbs. Current weight 195.

M1 -24; M2 -21; M3 -19; M4 -21; M5 -13; M6 -21; M7 -10; M8 -16; M9 -10; M10 -8; M11 -6; M12 -5.

H.A.L.A B.
on 5/2/18 2:41 pm

Trial you best to appeal it. But most likely it will not be approved. But ... You'll never know unless you try.

Hala. RNY 5/14/2008; Happy At Goal =HAG

"I can eat or do anything I want to - as long as I am willing to deal with the consequences"

"Failure is not falling down, It is not getting up once you fell... So pick yourself up, dust yourself off, and start all over again...."

KayLavonne
on 5/2/18 3:22 pm

Thanks, at least I can try. The worst they can say is no. My sis in law said they overturned the exclusion for her and we have the same insurance company in the same state with the same exclusion. However, she is a first timer whereas I am a revision. I will try. We shall see...

Johari22
on 5/4/18 9:14 am - San Antonio, TX

Hello,

I certainly hope that you are able to get your revision. Do you have any comorbidities that may help you gain evidence for the revision?

Sheila

LilySlim Weight loss tickers
A negative mind will never give you a POSITIVE result!
5' 8"
HW 292, SW 280, CW 270.0

KayLavonne
on 5/9/18 11:33 am

I have a hiatal hernia and bad GERD. That's about it.

(deactivated member)
on 5/4/18 2:34 pm

Hello,

I am in the same boat. My husband works for ATT. I had lap band done 3 times. Once to put in, 2nd because of a slip, and 3rd because of the port tube having a leak. Each time was a problem which I was too stupid to never take the dang thing out thinking ok this time it will work... Anyway I went to the Nicholson Clinic today and asked what should I do bypass or sleeve. He suggested to go for the bypass. I have manipulated my band so much I know how to work getting food down and my stoma is a little stretched. Not a big deal. But still. He also said that If I do this surgery. I will have to more than likely have two surgeries. One to remove it and let it heal and then come back because i prob have so much scar tissue it will be too difficult to do the surgery and a BIG risk. SO I am upset. Cash pay out of pocket is $18K and for the Sleeve is $10K in Dallas for Band removal and either surgery.Let me know how it goes for you. I am going to have to finance it all. If I can get a zero intrest that is the way to go. I can afford 6 years at 300 a month.

Mary F.
on 5/8/18 11:20 am - East Windsor, NJ

Self pay sucks, but maybe if you itemize all you medical expenses for the year you can deduct it from your taxes next year....

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