Insurance Exclusion

[time2getskinny 1]

Problem - my surgery advocate finds that there is an exclusion for the surgery I want (VSG) in my health insurance policy. They say I should - 1) get a copy of the stated exclusion for bariatric surgery from the insurance company (which I should get in the mail this week), 2) contact my employer's HR department to find out if they'd be willing to make a one-time exception for me to have this medically necessary surgery, 3) ask my HR department if they have alternative health plans with coverage for bariatric surgery that I can switch to at my next benefit enrollment, and 4) use the self-pay option (NOT an option!). My PCP said he'd write a letter and/or contact the HR department and/or my insurance company to see what he can do for me. Does anyone have any suggestions?? Thanks in advance!

[xavtay2 85]

Hello CarolynB,

I just experienced sort of the same thing with CIGNA! I was going thru the process of having the lapband and once the precertification paperwork was sent in Cigna denied me based an exclusion in our policy that specifically states in order for Bariatric surgery to be covered it has to be performed at a Certified Center Of Excellence. I was frustrated and I did 3 things: worked with my HR advocate, contacted the State of Fl Insurance Compliants and filed for an appeal and I wrote a formal letter of appeal and sent it into Cigna. It took about 3 weeks to her back for the state-still denied, it took 4 weeks her from my HR advocate to find another doctor (Which led me to the gastric sleeve) and about 6 weeks to hear from Cigna via my formal appeal. TO make a long story short I have now been approved to have any 3 of the procedures at any hospital in the state of FL. MORAL OF THE STORY don't give up! Something good will happen... Can't wait for you success story

[time2getskinny 1]

Thanks, Xavtay2!!

[Izuri 428]

I'm sorry to hear that you have to go through so many hoops to get it covered. How frustrating! I'm glad to hear Xavtay's story though. I'd follow their directions exactly and document everything you do, including the names of everyone you talk to. I find it's much easier to get things to go through insurance companies if I can provide some backup of who I talked to, what they said, and when. Good luck, I'll keep my fingers crossed for you!

[time2getskinny 1]

Thanks, Izuri!