Has anyone ever won an weight loss exclusion??

MyMeshelle · 06-29-2008, 11:26 AM

My INS policy has a weight loss exclusion... I am 31... and im 5'5 , 250 with sleep apnea and gerd... I have an appt with the DR i want to do my surgery on wednesday and i have gotten 2 calls from his office since i made the appt to let me know that i have an weightloss exclusion... which i already know! But they are making it seem like i have no chance to win if i appeal it... I plan on getting it done no matter if i win or not... i will finance it... but they are making me feel like fighting it is a waste of time?? Help!!

ccinlv · 06-29-2008, 11:58 AM

OMG! I could have written this post, I am in the exact situation that you are in. The office staff at surgical weight loss center of nevada in Las Vegas has basically said the same thing to me. I have California Ironworkers insurance and they have an exclusion and the office basically said "when you are ready to pay cash call us and we will make you an appointment with the surgeon" They didn't request any medical records, they didn't submit it to the insurance eventhough I have many co-morbities. I have since written my own letter of medical necessity, compiled all my medical records from all my other doctors supporting all the co-morbities. I made the appointment with the surgeon and I am going to talk to him about at least submitting it to the insuance company. I too will pay cash if I have to but I would at least likt to try and get it approved. I called the insurance company and they said yes there is an exclusion but approval is on a case-by-case basis. I go the feeling from the office staff just like you did that they didn't want to be bothered with it if it wasn't a sure thing right away.

Mink · 06-29-2008, 12:01 PM

I have not heard of anyone get coverage mine had an exclusion and I had to self-pay. One lady I spoke to said it is like buying a car without am/fm radio and desiding you want one even though you didn't pay for it. My employer put the exclusion in to save money.
Good Luck

MyMeshelle · 06-29-2008, 12:25 PM

Hmmm i wonder if its the same office... Whats the Doctors name?? I only know the Dr's name... Its Dr Teng... he is awesome but ya the staff is making me mad... cuz when i went to the seminar he told me to come in and we will appeal it... and then i make the appt and his staff keeps bugging... im gonna let him know this on wednesday... its like they dont want me to come in... im sure he wouldnt be happy to know they keep trying to cancel my appt when i plan on paying cash if i cant get the ins to pay... i just wanna see a denial and then i will move forward...

Northwest_Nance · 06-29-2008, 01:11 PM

My health insurance policy specifically excludes coverage for weight loss surgery. My employer did not purchase that coverage, so there is no way the insurance company can or will be persuaded to pay for surgery. I work for a fairly small company and in my employer's defense, at the time they negotiated the policy, there really wasn't anybody working for them who would be a candidate for weight loss surgery -- so why not save money on the premiums and pass that savings on to their employees? Their gain, my loss..... no pun intended!

MyMeshelle · 06-29-2008, 01:26 PM

A broker picked a health ins plan for our office... at the time i was pregnant so all i made sure she knew was that we needed maternity... even my boss didnt know we didnt have weight loss coverage... We are also a small business... Im fine with having the exclusion, well im not fine... im just not blaming anyone... i just dont get why the DR told me to come in so we can appeal it and then all his front office keeps trying to stop me from coming in...

ccinlv · 06-29-2008, 01:50 PM

No, I'm with Dr. Atkinson. I am still going to have them submit my paperwork but I am going to proceed as a cash patient.

It's_Christine · 06-29-2008, 01:58 PM

Unfortunately the MD may say things that they think are accurate but it's the office staff who deals with the insurance on a regular basis may actually "know more". You need to know if the "exclusion" is 100% or if they evaluate it on a case by case...which is not really an exclusion. Good luck

MacMadame · 06-29-2008, 02:10 PM

If it's an exclusion, you have to fight your company and convince them to buy the coverage. If it's an exclusion 'except in cases of medical necessity' you have to fight the insurance company to prove it's medically necessary.

I have the first sort of exclusion ... and my company is an enormous company that prides itself on it's great benefits package so I am PISSED ... but I decided to go self-pay and work with them so future people don't have to go through what I went through.

Jennifer77 · 06-29-2008, 03:40 PM

I work in a surgery center and I get phone calls like this all the time about insurance and just trying to submit the claim. We submit the claims regardless, but we know that they won't pay. We even try to appeal, but still they won't pay. Doctors offices and Surgery centers know who will and will not pay for certain services. They have been dealing with insurance companies for years. What is really difficult is when insurance companies change their policies. One year they cover something and the next year they deem it "not medically necessary". Patients come in and want to know why it was covered last year but not this year. We don't have the answer for that; all we know is that now we have a ton of angry patients who don't want to pay because they didn't have to before. When your Dr's office tells you that your insurance company isn't going to pay, they are doing it so that you don't bank on it. Some people think that they will be different and go through all the hoops with a false hope. And when it comes down to it in the end and the insurance company refuses and the patient then walks away and cancels. Then you are left with an office staff that has invested a lot of time and energy into a patient for nothing. And a patient that is sad and disillusioned thinking that they might be the exception to the rule. They really just want to prepare you for what they inevitably know is going to happen.

MyMeshelle · 06-29-2008, 03:49 PM

Thanks for writing... i am also in the medical field so i totally understand that... but i plan on getting the surgery regardless but they haven't even asked me if thats the case... i know the DR i work for would flip if my office was calling to cancel people...We strive to get people in the door... i just wanna see a denial and then i will self pay... i dont feel like im asking too much... ya its a lil more paper work but in the end they are getting $16,000 from me.... I love the DR who is gonna do my surgery but the front office has upset me enough to start calling around to other offices...

kgloverii · 06-29-2008, 03:57 PM

Just an FYI- I used to work for an insurance company... Namely BCBS. If there was an exclusion on the surgery, it was NEVER covered. No matter what health issues a member had, no matter ANYTHING. I am so sorry to tell you this, but you'll need to convince your employer to add that option on, or figure a way to self pay. My policy did not have an exclusion, but I was at a 40 BMI at the time I started investigating with no "real" health issues, so I just decided to self pay and not wait doing appeal after appeal. I've seen how hard it is from the member's perspective, and I just didn't feel I wanted to wait... I am really glad I did it 'my way.' I know that it is not an option for everyone, but I think a lot of self-payers agree. Good luck...

ccinlv · 06-29-2008, 09:07 PM

In 2006, the insurance approved the surgery but stated that I needed to try a 3 month medically supervised diet. During the last month I found out I was pregnant. Now fast forward to 2008 and the insurance said to the office that as of Jan 1 2007 there was an exclusion. I then found out that the exclusion is based on medical necessity. And 90% of the pre-approvals are denied. It has to go thru a separate medical review since they changed to a self funded plan. So I am taking out a loan against my 401K and going ahead as a cash patient.

tarheelluv · 06-29-2008, 10:33 PM

If I were you I would just forget about the insurance and go to Dr. Kirshenbaum in Denver. He is under $10,000 for everything and you just have to go to Denver once. He is so great I fly back and forth to Denver just to see him for fills. He is the best doctor EVER! Once after my surgery I had to call him on the weekend and he called me right back (I mean like a minute later). He immediately called me in a prescription. And he called the next day (Sunday) to check on me. I have never had that kind of service from a medical professional. He is awesome!!! And my incisions were terrific and my surgery went perfectly.