Not Covered! Any Luck on Appeals?

[UpandAtom 126]

Hi everyone,

I just found out today that my insurance plan will not cover any type of WLS - there is "a specific exclusion" for all of them. I am totally bummed!

They did say I could try to appeal with a physicians letter of pre-determination. Has anyone had any success with this? My insurance plan is UHC Choice Plus. Not so choice if you ask me!

[inittothinit 145]

^{Do you have any co-morbidities? I have been told that although the bariatric surgeon is the doc that submits for the surgery, the PCP's letter of recommendation has a heavy influence on getting the approval.}

[woo woo 872]

I have not yet heard of anyone with a policy exclusion getting surgery paid through insurance. Is it even possible I wonder?

[jujubslim 95]

Is this a group plan offered through an employer?

United health care typically covers weight loss surgery. However an employer can opt out of certain coverage. If it's your employer not covering then you may have a hard time with an appeal.

If it's United healthcare denying I would appeal, attach documentation from their website where they outline wls benefits. I'll look for a link if you need it.

I have read in forums about people's successful appeals. Good luck

[vdub_tx 92]

I was told that it is not possible. An exclusion is just that - an exclusion. It is a procedure not covered for any reason. But don't lose hope! Mine ended up being partially covered because I have a hiatal hernia. So my cash price was much more manageable. I would ask your surgeon's office to outline your options.

[SnohoGal98296 371]

I have an exclusion, I am selfpay, my HR even investigated getting WLS added on for this year, but we just didn't have the buying power. We only have 400 employees. A big company down the street that makes Commercial Aircraft, yes that one, is said to "give out weight loss surgery like candy" I even had someone ask me why didn't I just go work for them to get the surgery. .. But I am happily employed where I am.

Edited February 5, 2014 by SnohoGal98296

[gohelpyourself 377]

If your insurance does not cover any type of WLS then there is no appeal process. It is not covered.

[UpandAtom 126]

Thank you all for the replies. My plan is a group plan offered through my small company employer and they excluded this and other procedures to get a cheaper plan. I will keep on with the process and switch to my wifes plan in July. In the meantime, it's back to trying once again an my own.

[jujubslim 95]

Bummer. Don't give up you have options. Hopefully your wife's plan will cover it or you can buy a plan off of the exchange.