Denied. Service Not Covered.

[ArcusX 216]

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.

[SusieK710 130]

Mine was not coved either. Talked with the hubby, he asked how much would it cost for us to pay. He stated, "We could do that". Now I'm post-op. Definately got the secondary insurance. I drive a 12 year old Jeep, instead of replacing it soon, we invested in me. I'll be the sportscar!

[DanaL 118]

Try and see if your doctor would be willing to do a peer to peer. I had Cinga and got denied as well, then my doctor had a peer to peer with a medical director or someone at Cinga and they had it approved.

[mrsschnauzerdude 1]

I'm sorry to hear that. Can your surgeon and primary care doctor write letters of appeal? It doesn't hurt to try. Good luck to you.

[PdxMan 4,292]

I was not covered, either. Took a second on the house. Have it paid off already with all of the medical and food savings.

Try to figure a way to pay for it if you can. It was so worth it for me.

[johnlatte 1,232]

Don't give up dude, There are ways to get this done. Peer to peer, letter writing, even OOC (more affordable). Just keep at it, it will happen!

[SerendipityHappens 1,594]

Mexico baby... $4500 covers all surgery expenses, ground transportation, two nights in the hospital, and three nights in the hotel. The doctors are super experienced and all is arranged through American companies.

[Butterthebean 8,146]

Don't give up. Appeal!!!! But even if they don't pay, try to make it happen.

Knowing what I know now, I would do anything I had to if my insurance had not paid. It's just too beneficial, too important. Your life is in the balance. Invest in yourself or you may not live to spend your 401K.

[Butterthebean 8,146]

I was not covered' date=' either. Took a second on the house. Have it paid off already with all of the medical and food savings.

[/quote']

Haha....but those savings are offset by all the new skinny clothes.

[Beautyandbeyond 227]

Wow...can you share your stats with us? Any co-morbidities? What is your bmi?

I just don't understand these insurance companies denying ppl who need the surgery. It's just not right!

[ArcusX 216]

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.

[ashley18 8]

Yea what is your BMI? And do you have any other medical issues or is it just being overweight?

[ArcusX 216]

Wow...can you share your stats with us? Any co-morbidities? What is your bmi?

I just don't understand these insurance companies denying ppl who need the surgery. It's just not right!

BMI was 39.3. Now 35.5.

Comorbidities: Type 2 Diabetes, sleep Apnea, Acid Reflux

[JennyBeth 127]

I don't think you can appeal if it is not a covered benefit under your plan. It doesn't matter what your BMI or co-morbidities are, if it's not a covered benefit the insurance is not going to pay for it. I was supposed to change to my husband's insurance in jan. (Cigna) but bariatric surgery (of any kind) was not covered for any reason under their plan. I elected to remain on my own insurance (which is much more expensive) because mine covered it. I could never afford to pay out of pocket for the whole surgery.

[ArcusX 216]

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.