Insurance Says I Have Wls Exclusion, Wls Coordinator Says I'm Covered???

[audreycat123 59]

ok here's another one, you guys are awesome, I have asked my surgon's office coordinator three separate times if I am covered and i was assured that they would not have set up the appointments if i were not. However, when I call Anthem directly they state that i have an exclusion on my policy, twice they have said this.

Is the doctor's office just trying to rope me in, get me all excited for change, and they tell me i would have to self pay?That seems dirty. plus there is no way on Earth that I can self pay for this surgery.

Surely the coordinator knows what she is doing and was able to get around the exclusion with some jargony tech med speak? When I call i just ask if weight loss surgery is covered.

[Miss Cat 0]

Sounds VERY frustrating! You could try getting on the insurance company's website and look for the "Medical Policy." It should tell you whether WLS is covered, and what qualifications you must meet.

Hope that helps! Best of luck to you.

[Cocoabean 430]

What Mis Cat said. I called my insurance company and looked at my policy online. Don't trust someone in the Dr's office for this. For that matter, don't just trust the insurance company, that's why I say look online. With your membership card, you would be able to access the medical policy of YOUR coverage. Anthem has multiple policies. You want to be sure of which one you are talking about.

Best wishes!!

[NWgirl 574]

I had the same thing happen two years ago when I first started researching the band. I went to a local weight loss practice that had great reviews and feedback, submitted my insurance info to the practice so they could verify insurance coverage. I then was accepted into the practice as a patient and was given a letter detailing my coverage breakdowns.

Around the time I had read something disconcerting on the insurance website, so I called customer care and was told it was not covered under my specific policy. My insurance was through my stepdad, who works for a local health insurance group, and is able to choose from three seperate health care plans each year. The rep with insurance was really nice and actually did a three-way call to the insurance coordinator to find out what she was looking at for my benefits. It turned out she had ASSUMED I was on the one plan (out of three possible) that covered WLS, when in fact I was not and if she would have done her job properly, I would have avoided some serious letdown.

I guess the moral is, contact your insurance and don't trust someone through the Dr's office to find out important info like this.

[NWgirl 574]

ok here's another one, you guys are awesome, I have asked my surgon's office coordinator three separate times if I am covered and i was assured that they would not have set up the appointments if i were not. However, when I call Anthem directly they state that i have an exclusion on my policy, twice they have said this.

Is the doctor's office just trying to rope me in, get me all excited for change, and they tell me i would have to self pay?That seems dirty. plus there is no way on Earth that I can self pay for this surgery.

Surely the coordinator knows what she is doing and was able to get around the exclusion with some jargony tech med speak? When I call i just ask if weight loss surgery is covered.

PS: the coordinator who "helped" me also said that as a patient, I didn't know what to "say/ask" to the insurance company to find out if it was a covered expense. BUUUT, she didn't know how to read, so her advice was terrible.

[Ima Loser 197]

I work in the "insurance field" for a brokerage company... Typically if your insurance company specifically tells you something is an "exclusion" it means it is NOT a covered benefit... When you directly call your insurance company they are looking at your plan directly. Sometime in a Drs off the Insurance Coordinater is just speaking for an Insurance company in general. I would call Anthem's precertification department directly and ask if your plan covers the specific procedure that you are having done and what your specific benefits are... They will be able to tell you everything inculding all of your out of pocket costs, what requirements there are prior to surgery ie supervised diets, weight history, etc...

Personally I wouldn't trust the Drs office with this matter, maybe the insurance coordinator had spoken to someone about your plan directly have you asked??

Hope this all helps!! Good Luck!!!

[audreycat123 59]

this is what I found online under "exclusions" for my specific policy. What do you guys think?

Plastic, reconstructive, gastric bypass or cosmetic surgery except:

as connected with mastectomy (see the section entitled Medical Benefits)

> to the extent needed to improve the function of a part of the body (with the exception of teeth or the

structure that supports the teeth) that is malformed as a result of a birth defect, disease, or surgery

performed to treat a disease or injury

• Procedures, services, drugs and other supplies that are determined to be experimental or still under clinical

investigation by health professionals

[NWgirl 574]

this is what I found online under "exclusions" for my specific policy. What do you guys think?

Plastic' date=' reconstructive, gastric bypass or cosmetic surgery except:

as connected with mastectomy (see the section entitled Medical Benefits)

> to the extent needed to improve the function of a part of the body (with the exception of teeth or the

structure that supports the teeth) that is malformed as a result of a birth defect, disease, or surgery

performed to treat a disease or injury

• Procedures, services, drugs and other supplies that are determined to be experimental or still under clinical

investigation by health professionals[/quote']

If gastric is excluded, I'd dig further since most companies will cover gastric before they would cover lapband or sleeve. Look specifically under weight management and obesity treatment and see if it says something like "excludes surgery for weight related obesity," then it is not covered.

Sent from my iPad using LapBandTalk

[audreycat123 59]

arrgh, I can't find any sort of weight management or obesity section anywhere! Man I sure hope I don't have to go back to thinking i have to lose all this weight all by myself. That has soooo NOT worked!

[Cocoabean 430]

Call Anthem and ask them to send you their medical policy, and what the rep is looking at. As the previous poster said, they are supposed to be looking at YOUR policy. But I've had times where they were not looking at the right one. That is why I say talk to the company, go online, talk to your doctor's office, have your doctor's office talk to your insurance company. As soon as all are on the same page, you have your answer. Not before. It may be a dead issue if there is an exclusion, unless you can change carriers during an open season.

You are looking for their medical policy on obesity. Something like this:

http://www.anthem.com/medicalpolicies/policies/mp_pw_a053317.htm

That is generic to anthem, and not YOUR policy, which apparently has an exclusion. But search for "treatment of obesity" or under surgical coverage. Also check to see if it is excluded for other than medically necessary purposes..which I found on this link:

http://www.anthem.com/wps/portal/ca/visitor?content_path=visitor/f2/s5/t7/pw_a117000.htm&label=Exclusions%20%5E%20Limitations&rootLevel=1

You should have access to your policy's brochure. My policy explains coverage under surgical benefits.

http://www.opm.gov/insure/health/planinfo/2012/brochures/73-574.pdf See page 31.