Question:
Need help overcoming an exclusion-PLEASE
My insurance denied my claim, here is how the exclusion is stated in the book. "treatment for obesity or services performed primarily for weight loss or control (including gastric bypass and gastric staplings); but this shall not exclude procedures that are necessary due to a specific condition caused by another disease." PLEASE someone help me figure out the best approach for an appeal letter. My email address is [email protected] I GREATLY appreciate any and all help I can get. Thank you all so much!!!!!! — Dianne W. (posted on September 4, 2003)
September 4, 2003
I think they are saying you can have a gastric bypass but only if for a
non-obesity reason - such as cancer of intestinal problems. The other way
to read this is perhaps that they will cover it only if there is a
comorbidity. Unsure exactly which way they mean this. Sorry I can't be of
more help.
— bethybb
September 4, 2003
This leaves a door open but not much. Do you have sleep apena or diabetes?
Since there should be plenty of documentation that losing the weight
typically solves these medical conditions it is probably your best hope to
focus on them. Yes you are still having the surgery to lose weight but the
weight is creating these other very serious diseases. They still might say
thought that the weght is causing the other diseases instead of the
diseases causing the weight. This is likely to be a tough one to win but
definitely worth trying. Also make sure that your request was submitted
with a diagnosis code of MORBID OBESITY and not just obesity. They are two
totally different codes and diseases. Good Luck!
— zoedogcbr
September 8, 2003
Dianne, my exlcusion says <b>exactly</b> the same thing, word
for word. Do you have Unicare, by any chance? I too was denied because of
this eclusion, and when I called Unicare, the nurse told me that the
"specific conditions" caused by another disease are not
comorbidities, but, as Beth said, things like intestinal cancer. The only
recourse against an exclusions is, as I understand it, to appeal to your
employer. I sent my benefits administrator an email on 9/4, and I'm still
waiting for an answer.<P> Good luck with your appeal. Feel free to
email me if you have any questions.
— dreamsofa
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