weight loss surgery clause

[JudyDF 0]

My daughter just found out after going through 6 months of nutrional counseling and psych counseling that her employer had a clause in her policy denying weight loss surgery. Horizon told her she just needed precert and after six months was denied because of this wls clause. Does anyone know with this new health care bill will employers no longer be able to add this denial clause for weight loss surgery and if the clause is in policys can it be over-rided?

[Aquarius12459 0]

Does she have any comorbidities or other issues that would otherwise get her approved if it weren't for the clause and is her BMI 40+?

[JudyDF 0]

Yes her BMI is 40+ she also has narcalepsy. When she first called Horizon she was told her surgery was covered she just needed pre-authorization. She went through the 6 months of nutritional conseling and psych conseling and was just waiting for the final approval. She then finds out her employer put a weight loss surgery denial in her policy apparently Horizon never picked up on this when they first told her ok. She is devasted to say the least.

[CASSIEME1 1]

the job can do that no matter what insurance carrier you have.i have bc/bs my job has a wls/treatment clause.i ended up using charge cards.because i wanted it so bad i still wish i had more available on my card to have gotten the bypass.but on a more positive note on yesterday 3/22 my medicine doctor took me off my diabetic medication.so i can see some good behind all this hard work.

[BetsyB 9]

I don't think the health care bill will affect this sort of thing, but I could be mistaken.

Can she take it up with HR at her place of employment? When they renew the policies, they can opt to make changes to the policy. Some employers are willing to do this if there is demand from employees.

[Froggie D 1]

There are lots of studies out there about how losing weight, including weight loss surgeries, end up saving huge dollars for employers because employees get healthier. My employer added weight loss programs and weight loss surgery and are pushing it really hard to help employees be healthier. You might research this and present it to the employer.

Good luck.:smile:

[Aquarius12459 0]

Yes her BMI is 40+ she also has narcalepsy. When she first called Horizon she was told her surgery was covered she just needed pre-authorization. She went through the 6 months of nutritional conseling and psych conseling and was just waiting for the final approval. She then finds out her employer put a weight loss surgery denial in her policy apparently Horizon never picked up on this when they first told her ok. She is devasted to say the least.

Is there anyway that her surgeon can resubmit it to the insurance company and write a letter to her employer? Was thinking that maybe on a case by case basis they could adjust it if it was deamed "medically necessary" as opposed to just wanting the surgery and having co-morbidities?

My half sister went though heck and high Water with their insurance company before she finally got the OK for the RNY surgery. She was nearly 500 lbs (long story - 2 knee surgeries that we not successful and then she ended up not being able to hardly walk, let alone exercise) and lost about 50 pre-surgery. She had to submit the paperwork 3 or 4 times because they kept saying that it was "cosmetic and elective" surgery and not medically necessary. This was several years ago. She now is down to around 240-260 range but has probably 30-40 lbs of sagging skin that the insurance company will not approve the surgery to remove the excess skin from her stomach and arms and legs. It is sooooo frustrating because it really should be a package deal if they approve the weightloss surgery.

[BetsyB 9]

If the excess skin is causing infection or back pain or anything that is more than simply cosmetic, she needs to go to the doctor routinely to complain of [fill in the blank--itching, pain, weepy rash, neck and back pain, loss of mobility...] and have the doctor document her complaints and prescribe a remedy (prescription cream, physical therapy, special medical-grade corset, whatever...)

She should photograph all rashes with date stamps.

Document, document, document. It may not result in full coverage for reconstructive surgery, but it can take it out of the realm of "cosmetic" and into the realm of "medically necessary" so that partial coverage is given.

(I don't think I know anyone who's ever had insurance cover arms, though--breasts and belly? definitely workable.)

Writing a letter to the insurance company will be wasted effort. They go strictly by what is in their contract. The employer is who needs to make changes. They chose that policy, probably to save money.

Demonstrating to the employer that the costs of obesity and related conditions (as well as employee time lost to illness related to these things) is greater than the cost of surgery is the way to go.