Not Covered....

[kari_berry 0]

Well - I've just spent the last little bit reading through my entire insurance benefit book. I read every page - word for word...literally.

I came up with 3 different things - and they were all in 3 different sections. Here they are in the correct order in which they were found, and what section they were found in....

-------------------------

Hospital - Inpatient

Medical Conditions

"Confinements for the purpose of weight reduction (including gastric by-pass, stapling, ect.), unless Morbidly Obese."

-------------------------

Laboratory / Pathalogical Testing

"Tests associated with weight reduction or smoking cessation programs"

-------------------------

Surgeries

"Surgery for the purpose of weight reduction (Examples: Gastric by-pass, stapling, ect...)"

-------------------------

It states that NONE of the above are covered I'm kinda bummed.

The first one throws me off though - where it says, "Unless Morbidly Obese"

Now - since my insurance states that none of these listed are covered, does this mean that the surgery is NOT possible at all? Can I try it - and appeal? This is all new to me, so I'm sure I will be confused with it all.

Has anyone been able to get the surgery when the insurance first says that it is not covered?

Thanks for any replies!

~ Kari ~

[New Hope 37]

This is very confusing! Where's Alexandra? Sounds like you need to call your insurance company direct and find out for sure. Don't give up yet! Good luck!

[kari_berry 0]

Thanks I'm sure I will still call - but from what it looks like - it is a big "no".

It pretty much states that this surgery is not covered. I just wouldn't know where to go from here now. Is fighting them an option if they definatly say no?

I wonder if down the road - there would be a way for me to find an insurance provider that covers this surgery. I'd have to pay the premiums out of my own pocket - but wouldn't it be worth it?

Guess I may have to check into that down the road. lol.

Anyways - as always - thanks for the reply!

~ Kari ~

[elbell 0]

Kari

first off I half to say I wish I had the guts to do what you are trying to do when I was your age. My story Is about the same, I have ben over wight nearly all af my life and after going threw a life changing event I decited to do something about It! Unlike you It clearly states in my insurance booklet that they will not cover any type of WLS. So I am going anouther rout of self Pay with a family friend. All I can say is talk to your Iusurance co. and push on them. If you don't get a yes the firest time find out what there appeal proses is and follow it by the letter!

good luck to you and keep us posted

Ellen:)

[GeezerSue 7]

"unless morbidly obese" is the last part of a sentence...what does it say BEFORE that part?

Originally posted by kari_berry

Well - I've just spent the last little bit reading through my entire insurance benefit book. I read every page - word for word...literally.

I came up with 3 different things - and they were all in 3 different sections. Here they are in the correct order in which they were found, and what section they were found in....

-------------------------

Hospital - Inpatient

Medical Conditions

"Confinements for the purpose of weight reduction (including gastric by-pass, stapling, ect.), unless Morbidly Obese."

-------------------------

Laboratory / Pathalogical Testing

"Tests associated with weight reduction or smoking cessation programs"

-------------------------

Surgeries

"Surgery for the purpose of weight reduction (Examples: Gastric by-pass, stapling, ect...)"

-------------------------

It states that NONE of the above are covered I'm kinda bummed.

The first one throws me off though - where it says, "Unless Morbidly Obese"

Now - since my insurance states that none of these listed are covered, does this mean that the surgery is NOT possible at all? Can I try it - and appeal? This is all new to me, so I'm sure I will be confused with it all.

Has anyone been able to get the surgery when the insurance first says that it is not covered?

Thanks for any replies!

~ Kari ~

[kari_berry 0]

GeezerSue... This is what the first part (that says "unless morbily obese) states. (It is about two pages in the book - but here it is). Hopefully this will help. The part that I am talking about is bolded

Thanks -

~ Kari ~

------------------------------------------------------------------------------------

HOSPITAL-INPATIENT

MEDICAL CONDITIONS

Hospital inpatient charges are covered as provided below.

Hospital confinements should be verified through the hospital

verification system. Days of care that are not verified will require

documentation of the need for inpatient care in order to be

considered.

FOR:

Admissions for a covered surgical procedure, an illness (including

pregnancy) or the medical treatment of a life-threatening medical

emergency or an accidental bodily injury

Hospital room and board charges for a semiprivate room, coronary

care unit, intensive care unit, special care unit and isolation

Hospital extras during a covered hospital confinement

Charges of a skin bank, bone bank and other tissue storage banks

Prosthetic appliances, either surgically implanted or external

Confinement solely for physical therapy for rehabilitation following

a hospital confinement for the same illness or injury

Hospital confinements for laboratory testing and x-rays when

medically necessary due to a concurrent hazardous medical

condition

Respiratory therapy by a licensed respiratory therapist

Charges for a private room in excess of the semiprivate room rate

Rest cures

Hospital confinements for procedures which are not covered by

this plan

Charges for patient convenience items, including - but not limited to -telephone,

television, guest trays, and guest beds, etc.

Confinements for custodial care or physical check-ups

Weekend admissions for conditions other than a life-threatening

medical emergency or accidental bodily injury

MEDICAL CONDITIONS (Continued)

FOR:

Confinements prior to the day of elective surgery

Days of confinement not verified by the Plan Supervisor or

supported as necessary by medical records

Services rendered in a hospital operated by a municipality, state

(except the Medical College of Ohio), the U.S. Government or an

agency of the U.S. Government, except in a V.A. Hospital for an

illness or injury that is not service related

Hospital hotels

Confinements for the purpose of weight reduction (including gastric

by-pass, stapling, etc.), unless morbidly obese

Days charged when the patient is on leave from the hospital

Charges for 23 hour outpatient observation care in excess of the

cost of one day care at the hospital's semiprivate room rate

Hospital confinements during which only dental procedures are

performed, except when necessary due to the age of the patient, a

concurrent hazardous medical condition or a medical need to

utilize the facility

Hospital confinements which begin before the covered individual

is eligible for benefits

Charges for room and board by a facility which is not defined as a

hospital

------------------------------------------------------------------------------------

[kari_berry 0]

Also - this one is from the "Surgery" section of the book. Below is the list of what they do not cover...

------------------------------------------------------------------------------------

Surgery for the purpose of weight reduction (examples: gastric

bypass, stapling, etc)

Sterilization reversal

Artificial insemination, in-vitro fertilization or embryo transfer

Cosmetic surgery, except when:

· necessary due to an illness or

· as a result of a congenital defect which interferes with bodily

functions

· for scar revision to correct a deformity caused by an

accidental bodily injury or surgery

hair removal or replacement

Surgery and associated charges for the correction in the size or

shape of any part of the body

Face lifts, eyelid lifts, skin tucks or excision of fatty tissue

[Alexandra 55]

Hi Kari,

First, what you've posted seems contradictory. In one section it seems to go straight from a list of what is covered to a list of exclusions.

This looks like a list of what IS covered, right down to the line I've marked:

HOSPITAL-INPATIENT

MEDICAL CONDITIONS

Hospital inpatient charges are covered as provided below.

Hospital confinements should be verified through the hospital

verification system. Days of care that are not verified will require

documentation of the need for inpatient care in order to be

considered.

FOR:

Admissions for a covered surgical procedure, an illness (including

pregnancy) or the medical treatment of a life-threatening medical

emergency or an accidental bodily injury

Hospital room and board charges for a semiprivate room, coronary

care unit, intensive care unit, special care unit and isolation

Hospital extras during a covered hospital confinement

Charges of a skin bank, bone bank and other tissue storage banks

Prosthetic appliances, either surgically implanted or external

Confinement solely for physical therapy for rehabilitation following

a hospital confinement for the same illness or injury

Hospital confinements for laboratory testing and x-rays when

medically necessary due to a concurrent hazardous medical

condition

Respiratory therapy by a licensed respiratory therapist

==>Charges for a private room in excess of the semiprivate room rate

==> Rest cures...

Those two lines and everything BELOW that would seem to be things that are NOT covered, at least in most normal plans. If that's reproduced correctly, I think you should question the accuracy of your documents.

Secondly, that phrase "unless morbidly obese" is your key to everything. It represents a loophole through which you can jump right into banding. Your doctor will declare that you ARE morbidly obese and surgical treatment is necessary. He will very likely have to make the case that other treatments have failed and are likely to fail again (that's why you'll need a detailed diet history), and that you are a good surgical candidate (that's why the physical and pre-op testing).

Based on what you've copied here you are still in the dark because it's self-contradictory. I think your next step is to call the carrier and ask for clarification of the surgery exclusions. Mention that you see the qualifier "unless morbidly obese" and that you want to confirm it is true.

[kari_berry 0]

Thanks Alexandra

Glad that you might be able to make some sense of this. It seems like they make this so difficult so no one can understand it...lol.

I've felt a little bummed since finding this info - but I'm not prepared to give up. I believe that there is a loop hole here too - and I REALLY want to jump through it.

I figured I could also argue with their statement that is throughout the entire book. It says - "Unless Medically Necessary". Well - I believe that this is medically necessary, and I'm sure a doctor would agree.

*** Now I have some questions...

How much proof should you have that you have tried many diets, ect??? I have three records from weight loss centers where I have tried to lose weight. One from back in 1996, 2003, and 2004. Plus back in 2000/2001 I was on Xenical for a while, which obviously didn't work. Plus I have a long list of other diets I've been on.

Should I write this list down? Should I try to include dates?

If I go to my physician for a physical, and talk to him about the Lap-Band, what will happen from there? My experience with doctors is, that they note what you asked them, but never try to refer you anywhere, or encourage you to follow through.

After seeing my physician - how do I get this process rolling with my insurance company? (I'm REALLY lost there!) lol.

I've seen that some Lap-Band doctors in my area offer a program where people come in, and they talk all about the procedure, and it's free (kinda like a consultation). After that - do I contact the office of the surgeon that I plan to use, and have them start the insurance process for me?

Sorry for all of this being so long. You have all been so very helpful to me, and I appreciate all of the advice that I am given.

Thanks SO MUCH for everything!

~ Kari ~

[Alexandra 55]

How much proof should you have that you have tried many diets, ect??? I have three records from weight loss centers where I have tried to lose weight. One from back in 1996, 2003, and 2004. Plus back in 2000/2001 I was on Xenical for a while, which obviously didn't work. Plus I have a long list of other diets I've been on.

Should I write this list down? Should I try to include dates?

Yes, you should write it all down. My list of failed diet attempts was three pages long. Start making notes now of your weight history, diet attempts, results, and aftermath. Like so:

"1981-2: Weight Watchers for 9 months, lost 20 lbs, gained 40 back in the next year. Ended 1982 at 250 lbs."

If I go to my physician for a physical, and talk to him about the Lap-Band, what will happen from there? My experience with doctors is, that they note what you asked them, but never try to refer you anywhere, or encourage you to follow through.

You have to be proactive here, but the exact next step depends on your insurance plan. You'll need to identify an appropriate surgeon no matter what. (You can do that in several ways--I started by searching Inamed's list of banding doctors to the list of participating surgeons in my carrier's network.) Then, if your plan requires referrals, ask your PCP for a referral to one of the doctors you've found who does banding surgery.

After seeing my physician - how do I get this process rolling with my insurance company? (I'm REALLY lost there!) lol.

Once your PCP has recommended bariatric surgery for you and you've found a good surgeon, the next step is to meet with that surgeon. It's your surgeon's job to request precertification for surgery from your carrier--not yours.

I've seen that some Lap-Band doctors in my area offer a program where people come in, and they talk all about the procedure, and it's free (kinda like a consultation). After that - do I contact the office of the surgeon that I plan to use, and have them start the insurance process for me?

Yes, these seminars are designed to educate the patients quickly and efficiently. Some doctors make them mandatory (like mine, for example), but it's a one-shot deal. It's not a consultation and is not personalized. You will need to make an appointment for examination with the surgeon.

There's no "process" with the insurance company yet. Your first steps are to get medically assessed and have the surgery prescribed for you, and that alone will take some time. It's not until the surgeon has made his determination about you as a patient that anyone makes any formal requests of the carrier. Any medical visits you have should be handled like any other medical care you receive--just do what your carrier requires per usual. Start with the physical and see what's next.

In my case, my PCP first recommended an evaluation by an endocrinologist, because she found evidence of hypoactive thyroid. So there was treatment for that. There were followup visits, and so forth. All of this takes time, but I made sure that every doctor I saw knew I was trying to tackle my disease of morbid obesity. That was the condition for which I was seeking treatment. I didn't make the decision to have surgery; that was recommended by my doctors BECAUSE other things had not worked.

Getting your carrier on board involves getting your doctors on board FIRST. So start there. And keep us posted!

[kari_berry 0]

Thanks so much again Alexandra - you have answered ALL my questions to a T. Now I feel like I know where to start!

I will sit down today and write down everything that I can remember in my dieting attempts. My mother remembers some things from when I was a younger child, so she can help me out with this too. (I told her that I'm looking into the surgery - and she is very supportive.)

Soon - I will make an appointment with my PCP and go from there.

I will be sure to keep you all updated.

Thanks SO MUCH again for taking the time out of your day to help answer my questions

~ Kari ~

[Alexandra 55]

Kari, you are more than welcome. You're so smart to be asking these questions and not letting one reading of a muddled benefit booklet scare you off. Good for you!!

[kari_berry 0]

You have to be proactive here, but the exact next step depends on your insurance plan. You'll need to identify an appropriate surgeon no matter what. (You can do that in several ways--I started by searching Inamed's list of banding doctors to the list of participating surgeons in my carrier's network.) Then, if your plan requires referrals, ask your PCP for a referral to one of the doctors you've found who does banding surgery.

Alexandra - I found out that with my insurance provider - we do not require referrals for any kind of doctor. As long as he/she is within our network.

Should I still try and get a referral from my PCP? I just figured it looks better if your doctor refers you somewhere.

Thanks again!

~ Kari ~

[Alexandra 55]

Kari, no, there's no reason to get a referral from your PCP to a surgeon if your insurer doesn't require it. "Referral" is a specific word with a specific meaning in the insurance world, and if you have a PPO it's just not relevant.

Your PCP will have to be on board, though, if your insurer wants more than your surgeon's word that treatment is medically necessary. Most carriers do need a letter from the PCP attesting to the patient's overall health and weight history, etc. So definitely go through with that physical and make sure your PCP makes that all-important diagnosis. If your PCP puts in a claim for the appointment, that diagnosis code will show up and that's just more ammunition for you.

[GeezerSue 7]

Just adding that, from what i can tell, that loophole is right there. Hosptializations for surgery for someone who is morbidly obese ARE covered. We know that because they say that confinements for bypass type operations are not covered unless the patiente is morbidly obese...which you are, so there we go.

By the way, Blue Cross and Aetna (and others, I guess) have the coverage policy bulletins online. Have you checked your insurance to see if the policies are online?

Sue