Insurance?

Hello VSGers

I am in the middle of an insurance battle right now. I was told that it wouldn't be covered initially, and then I appealed the initial decision. Throughout the appeal, I was under the impression that my sleeve surgery would be covered. I just found out this afternoon that my appeal was denied. There is still a chance for a second round of appeals, but I am getting discouraged.

I was wondering if any of you have gone through a similar process? How many tries did it take? Or were you flat out denied? Any suggestions or advice (or just plain commiserating) would be appreciated. :)

Why are you being denied?

Do you have coverage for WLS?  Have you met all the requirements?

My insurance states that they do not cover WLS "unless medically necessary". My doctor says that my BMI (over 40) makes WLS medically necessary. As far as the requirements go, I have done the 3 months supervised weight management (classes, nutritionist, psychological testing, lab work, etc etc etc) and all of these were covered.

After speaking with customer service today, they said it was denied because WLS is a "contract exclusion". But I have heard that most people get denied the first time around, and then get approved after appealing. Maybe that's just wishful thinking....?

A contract exclusion would imply that your employer or whoever you get your plan from excludes WLS.  That the insurance company may only have WLS as an option if your employer opts to cover it.

You should call your HR/employer or your insurance company and get YOUR specific policy description (summary plan description) and the specific policy for WLS requirements.  That description will outline what is covered for WLS and what requirements you need to meet (like specific BMI or comorbidities). 

Good luck!