Bariatric plan exclusion?

[smadams 0]

Just curious if any of you have insurance that considers bariatric surgery a plan exclusion, if you fought the plan exclusion, and if you were able to get it covered? I know you can fight these for medications, so it HAS to be possible for surgeries, right? My BMI is 52, I have sleep apnea, asthma, and a previous diagnosis of pre-diabetes, but those are the only comorbididties I have that are "official." Other conditions are osteo and rheumatoid arthritis, endometriosis, depression, and anxiety.

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[Shereseed 24]

Mine was specifically excluded. I was denied over and over again, with a higher BMI. I just got back from Mexico, where I had it done. So far, so good. Definitely worth it.

[MSinger 348]

From my understanding, plan exclusions are typically non-negotiable situations. I'm sorry if that's the case with your insurance. It's ridiculous that something that could help prevent or reverse so many chronic conditions is not considered worth covering.

I second the suggestion of looking into Mexico. Lots of folks here had their surgery over the border. Good luck.

[Diana_in_Philly 1,426]

I've been doing insurance-related legal work for 30-ish years. The odds of a carrier deciding to cover something that is specifically excluded is almost negative. Consider, from their point of view, the consequences - if they say yes to your bariatric, which was excluded, they will be in the position of having to argue that the exception made then should not apply to the plastics you will need related to bariatric surgery. So sorry it isn't covered by your plan. It's not like an experimental drug or new drug that may not be on the formulary. Best of luck.

[smadams 0]

Thank you everyone! I'm going to look into the marketplace to see if there's any plans that WILL cover it for next year, and in the meantime, I'm going to go through my HR department to see if I can get them to offer a plan with it. I'm kind of leery of going to Mexico for it, only because some PCPs will refuse to help you after surgery, and I don't want to lose mine lol. I will do it as a last resort though. I will NOT give up!

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[Barbara1972 13]

My employer specifically has it excluded on our health plan. My insurance company told me that I would need to talk my employer into re-negotiating their contract and removing the exclusion for future year coverage. I've seen some template letters online here and there that can be used to present to your employers HR department but this would be a long uphill battle. In these cases when your employer excludes it, it really not up to the insurance company. Good luck. I'm going RNY via self-pay and it's scary since insurance won't cover complications either, but I believe it's worth the risk.

[OutsideMatchInside 10,166]

@smadams

What state do you live in? A lot of states do no consider bariatric surgery a necessity so no marketplace plans will cover it either. Good luck if you live in a red state.

[mlands 5]

I talked to my Dr about it and he assured me he would take good care of me after my sleeve in Mexico. He has already had another patient have it with no problem and he said he took care of her also. I am looking at September only bc I can't get into Dr Illian before then. He is booked. Good luck everyone!