ArcusX

Best case scenario, they'll cover it for re-enrollment in June. But at least I'll have said my peace. I'll not pursue it further with them. If they do not make changes, my choices are to either look for a new job, self pay, or not do surgery at all.

Please do. I spent a lot of time looking for relevant and CURRENT statistical information. My reason for posting it here is maybe my time will be made more useful if others can benefit from it too.

Thanks. Edited! Don't want to get into any trouble

After getting a letter over the weekend from insurance looking for more evidence of "medical necessity," I got another letter yesterday informing me that I was denied. Reason: "The service you requested is not covered." "We found the service requested is not a covered benefit in your case." "Exclusions, Expenses Not Covered and General Limitations." It's not a complete shock. I had called Cigna before I even had my first consult and was told the same thing. I went through with the consult and I as assured up and down from the insurance coordinator, whose job it is to verify coverage, that I was, in fact covered. Wanted to believe her, and that I had just caught an idiot on the phone at Cigna, I pressed on. I'm a disappointed, but not devastated. I'm probably as much angry as disappointed; I'm out of pocket somewhere in the neighborhood of $1000 for all the pre-op stuff (EGD, etc.). I want recourse on that, but I'm sure it will amount to nothing. Going fully out of pocket isn't much of an option. I don't know. I guess I just keep on with this diet I've had myself on. I've been generally successful, but it's starting to get harder now, three months in.

You know... I never get tired of hearing that!

Hi Iggy, I think you are spot on. I work for a Fortune 400 company $8.78B in annual revenue. I understood from the get-go that the company's decision not to cover WLS in any of its medical insurance offerings was purely negotiating a lower premium. I don't know what the statistics are, but I'd be willing to guess that there's a very small percentage of people who even consider WLS as an option, and likely those who consider it, give up after finding out that it's not covered. I would have, if I hadn't already gone through all the pre-op stuff. Having said that, it sounds like you may be a good resource to advise how I might proceed with at least giving my feedback to my employer's HR department. I've been thinking I would write a letter to the SVP of HR, opening with something like, "How many morbidly obese 80-year-olds do you know?" Probably not many. Then go into pointing out statistics, and finish up with urging them to reconsider their decision that was made a long time ago based on data that is probably 10 years old, relative to complications and their claim costs, vs. the benefit. I'm not afraid of doing that, but moreover, I hesitate to leave this in the hands of just one person. In other words, I feel like an executive both in and outside of HR should hear the information. How stupid would that be?

Iggy, stop justifying your actions. The thought of writing a letter is moving. Even an older child who might remember those talks would probably cherish a letter throughout the rest of their life.

There's an ignore function on the site. You should use that, rather than repeatedly post negative comments against another user.

One word: X-Lax!

When the thought of WLS first entered my mind and I began to do the research, I thought the same thing: "liquid diet? Who wouldn't lose weight? With more research, I realized that it's not just the liquid diet. It's the limited capacity, plus the reduction of the hormone that makes you feel hungry. That's the real difference. Much harder to fail, even if you wanted to.

Ugggh!! I can relate to that. I think... I know, the only reason my wife's okay with the surgery is because I won't be able to drink alcohol for several months. She is excellent at sabotaging my weight loss efforts.

Yeah, she said she wins about 50% of appeals. Not hanging my hat on that one, but I'll be patient.

My eyes read, "cash" PRIZE. LOL. I guess cash/finance could be an option, but I think it would be a while...

Wow... Apple is really branching out!

Supposedly, they did. She told me she had the name of the person who verified coverage too.

Unfortunately for me, we bought two new cars last year, and paying around $1k/mo between them. I wish I could put my wife back to work! lol

What is OOC?

The thought of Mexico scares me, to be honest.

I just got off the phone with the insurance coordinator, and she's fired up and moving to appeal, peer to peer, etc. I pointed out about my employer specifically excluding it, but that didn't discourage her. She's also going to send me an article with recent statistics that I can use to fight on my end with Corporate HR.

BMI was 39.3. Now 35.5. Comorbidities: Type 2 Diabetes, sleep Apnea, Acid Reflux

Thanks all. I'm not sure appeal is something I can do. It's a part of the policy my employer opted not cover when they negotiated the insurance. They offer Kaiser too, and was told they don't cover it there either. Here's the email from the benefits coordinator: We don’t cover it due to the other complications that can arise from this particular surgery which in turn can cause higher claims. I have been here for 8 years and we have never covered it. You are correct we are big on wellness and promoting healthy lifestyles for our teammates, we just promote through healthy eating and activity programs as well as screenings etc.

After having been submitted to insurance on 12/19, I received this in the mail over the weekend: Dear DOUGLAS KRAHN, MD: We received a request from you on 01/08/2013 for JOHN for coverage of the following service(s): • Laparoscopic Gastric Bypass (43644) After review of the information submitted, we are unable to substantiate medical necessity for the requested service(s). To process your request, we need the following additional information: • Fax any pertinent clinical information supporting the medical necessity of the services requested to 1-800-558-3710. Please refer to CIGNA's Coverage Positions at www.CIGNA.com. Please be aware this is not a denial. Once clinical Fun...

I'd recommend getting out and doing things you like to do. Bowling. Library. Pool (billiards or Water ). Whatever your hobby is. Or was. Or would like to be. Know what you'll find there? Other people who like to do the same thing! Good luck!

Somehow I missed that. Is there a link or something you can point to? I had gotten an invite to the SoCal VSG Support Group, but there didn't seem to be any activity there.

Hi Amber - Riverside here, too Congrats on your sleeve. How are you doing?