Confused... Insurance says no, doctor says "come on in"

Today, I was finally able to get a live human being on the phone from my insurance company (Anthem) to get info on my coverage for bariatric surgery.  Unfortunately, the lady on the other end of the line told me the policy my company has doesn't cover wls.

So, after a couple of stunned and disappointed moments, I started thinking that maybe I could appeal their decision.  I didn't want to waste my time or a doctors time if no is no, but I knew I needed to ask more questions. 

I called the office of the surgeon I would like to work with, and I explained what the insurance company said.  The lady at his office said that the answer I received from my insurance company was a common response as several of them don't include bariatric benefits on their policies.  She said it definitely wasn't the end of the road from their experiencce and said I should still come in.  She also said they've worked through this scenario before with Anthem.

I asked if there was anything I needed to bring with me, and she asked if I have any other health problems.  I said yes, I just had a Endoscopy done last week because I have GERD and they found a hiatal hernia during the procedure.  She said to bring all of the documentation I have on these issues and that they both basically punched my ticket so I should be able to get wls because of them.  I guess they are considered co-morbidities??????

My appointment is scheduled for Thursday 9/1.  I have to admit that I am excited about it, but I am so concerned that I might end of really disappointed ultimately too.  My procedure would be a revision of a stomach stapling done over 20 years ago and I know this might complicate things a bit more.

What I'd like advise on is whether or not the insurance companies usually say no at first, and if the co-morbidities might help me in the long run.  I don't want to waste a doctors time if this isn't going to happen when he could be helping someone else.   But, if the co-morbidities help, will it make the surgery happen quicker?  I know sometimes insurance companies want us to do supervised diets for awhile, and I am just wondering if that's still the case when there are co-morbidities involved.

You are all so informed and helpful with others that I'm hoping you might be able to help me too.

Thanks in advance!

 I would go in and see them.  One of the surgical treatment for severe GERD is RNY.  It is still relatively new treatment, but it is being done instead of the Nissan Fundiplications of the past that were used to treat severe reflux.   There always seems to be a back door!!  Good luck at your appointment!!

Kat

Yes, those are comorbidities, but if your insurance policy doesn't cover WLS, I doubt it will matter.

See, when you buy insurance, the cost of the insurance depends in part on what things it covers.  Like, you can buy car insurance that will only cover damage you do to someone else's car but not damage to your own car.  It's cheaper than buying insurance that covers your car as well as any other car you damage.  But if you only buy the insurance to cover someone else's car, and then you're in a wreck and your car is hurt really badly, your insurance is not going to cover that damage because you did not pay for that coverage.

Some employers choose to exclude WLS from the insurance they offer to employees because it's cheaper that way.  It sounds like that is the situation here.

No, I don't think insurance companies usually tell their subscribers that their policy does not cover WLS if it really does cover it.  I don't think they would routinely lie to you about your coverage.

If you have not paid for WLS coverage, then I doubt they will pay for it even if you have comorbidities and really, really need it. 

If your policy does cover WLS, though, then comorbidities may make it easier to get approved.  I don't think they waive the requirement for a supervised diet if you have comorbidities, though.  That would depend on your policy, though, different policies have difference requirements.  Some don't ever require a supervised diet.

I guess all you can do is see what the dr's office can do for you. Insurance policies are usually pretty firm on their coverage limits, though.

Perhaps you might want to call you ins. co back and ask if they can send you the portion of your contract benefits that explains why you wouldn't be covered for WLS.  If it is because it requires co-morbidities it will say that.   If it is because the employer's plan they purchased doesn't cover it, it should say that.

If it is because the plan your employer purchased doesn't cover it, does the employer offer more than one type of plan to chose from?  If so, you might want to look into whether any of the other plans cover it when it comes time to chose your new benefits.

If not, and you are with a small company and you are comfortable talking with your boss, perhaps they would look into what a plan with a WLS benefit might cost them/you for next year.  You might state that it would not only be a huge physical/emotional benefit to you, but as an employer he would gain because you would be in better health and perhaps require less sick days.

Food for thought (no pun intended)

Although those are comorbidities that would be considered for eligibility if your insurance policy covered WLS, if your company's policy specifically excludes weight loss surgery, it won't matter what comorbidities you have. If it is an exclusion to your policy, there is no "decision" to appeal, and even though gastric bypass does help with all sorts of conditions, it is not the ONLY treatment for ANY of them.

Before you go in to see the surgeon (because, if your insurance has a WLS exclusion, they may also refuse to cover the cost of the office visit with the surgeon), get a copy of your policy if you do not already have one (if you work for a larger company they will probably have it online; otherwise someone in HR should have a copy) and see if WLS is listed under the exclusions section. If it is, you are out of luck unless you ahve the option fo switching to a different plan that might NOT have an exclusion. 

Lora

mine was denied and had to be appealed . i couldnt get a date until i was later approved. or u will have to pay out of pocket. u may want to double check for sure .

I paid, upfront, the full $24k+.  Not many companies pay it anymore.  Some union shops, government etc still do.

Athough I didnt have to do this, I look at it as worth taking a loan out and making monthly payments.  Most folks dont think twice about a car payment but wont spend the same for rebuilding thier health.

Best.

My neighbor was denied by her insurance but when she was diagnosed with a hernia, they covered it. The reasoning with her's was that the hernia would have covered the majority of the surgery costs and the additional for the RNY mas minimal and in their/her best interest.

I say go hear what they have to say. They will not run with it unless they are pretty confident that they will get paid.
Good luck!

I appreciate everyone's comments.  I am going to go on and see the doc because I've been reading some studies that do say in an obese patient, instead of doing a surgical procedure to treat the GERD problem, RNY is becoming more of the norm procedurally because of the benefits to the patient overall.  

If it isn't possible, then I'll go on to plan B!