Problem with Insurance

I have gone through the process of approval for Roux en Y at Duke Surgical Weight Loss Clinic. Some background about me. I have type 2 Diabetes and moved to taking Lantus in October. I also had back surgery in 2003. When I went to the clinic yesterday to finalize my surgery date, I was told that our insurance will not cover the surgery. We have Anthem through my wife's job. She is a teacher in our county. Anthem told the insurance person at the clinic that the policy had to have a rider added for me to have the surgery. Without the rider, they would not pay for the surgery. It is ironic that this is going on. My pharmacist tells me that my drug cost a year is over $4,000. If I have the surgery, my doctor tells me I will not have to take any medication for my Diabetes. I was wondering if anyone else has run into this problem. If so, what can be done about it. Thanks for the time.

Hang tough Mike. I've read dozen's of insurance rejections on this board that almost always turn into approval's over time. It definitely takes a lot of patience. It might just take having your doctor detail all your co-morbidities and current costs. Nothing speaks louder to insurance companies than the almighty dollar. Unfortunate but true. Have a great Easter. no

Hey Mike, Unfortunately, without the rider, my understanding is that there is nothing that you can do. I think the cost associated with the rider is quite large and companies are not able to add the rider for individual people, instead they have to add it to every person insured that works for the company. So in your case, it would be every person employed by the school district (or possibly the county)...I am not completely positive but that is my understanding. Sorry to be the bearer of bad news... Christine

Hey Mike. I don't have personal experience with insurance issues but I know quite a few people have mentioned their experiences. I am sure an appeal is the first order of business. I think there is an insurance forum on here. You might get a lot of helpful information from there. Keep battling for your health and your needs. Courtney

The saga continues. I got a letter from Anthem saying I have the right of an appeal. I do not understand this. Why send me a letter stating I can appeal if the surgery is not covered? Can anyone enlighten me?

I had the same happen to me. I have Anthem written exclusion also. I was denied after appeal and pretty much was told there was no hope that they would pay. When I made the appointment I was told that the GBS was covered. I went to the doctor then denied not only the surgery but the cost of the doctors visit and the $944 in blood work I had drawn that day. My blood work is covered 100% but they would not pay for the obesity related. ANthem claims I never called because they would have a record if I had called and they would not have told me something was covered when it wasn't.