Molina denied gastric sleeve

[TaraBailey 0]

My BMI is 47.3 but I don't have diabetes or other health problems does anyone know what I can do next to get approved ? If I don't get surgery and lose weight health problems could follow just don't understand why they wouldn't want to prevent them paying more money in long run . I am desperate ?? !!!

[The Greater Fool 2,002]

It's generally true that the costs for WLS are significantly less than later associated medical costs without WLS. Insurance companies do not expect to be paying your later medical costs. Thus, paying for WLS now is cash out of their pocket and some other insurance company (or entity) will reap the benefits of the lower costs later. "No" is nearly always the best answer for their bottom line now.

Some insurance companies won't cover WLS. There is virtually no way you can get them to cover it.

Some insurance companies cover WLS but make it very difficult (or have a reputation for making it difficult). For these there are several things you can do to improve your chances of approval:

1) Review the requirements and be sure you have documented compliance. Demonstrated morbid obesity (mine was 5 years), a medically supervised diet (mine was 6 months within the last 2 years). They have a list, you need the list and check off every item;

2) Comorbidities: If folks have a lower BMI sometimes insurance requires comorbidities. So, oddly, completely healthy is bad. Thinking outside the box can help: Back pain, knee pain, sleep Apnea, GERD, hernia, type 2 diabetic, anything even remotely connected;

3) If you get denied, find out EXACTLY why. It could be they don't cover it at all, or that a piece of documentation was left out. Find out from the insurance company;

4) Call the insurance company and ask for their help. While the insurance company may be loathe to cover WLS, the customer support folks get rated on how well you think they have helped you. I've never encountered an Insurance customer support person that wasn't helpful. If you get an agent that isn't helpful, call back and talk to a different one.

5) You are your best advocate. If you don't do the work it's unlikely anyone else will do it for you. People have changed where they work to get insurance that covers WLS. Figure out how far you will go to get it then don't stop.

Good luck,

Tek

Edited December 9, 2021 by The Greater Fool

[catwoman7 11,173]

I had one of those companies that did not cover WLS regardless of the circumstances. Luckily, we had a choice of insurance companies with my former employer, so I switched to one that covered it. But like Greater Fool said, if yours claims they cover it but is just making things difficult for people to get it, then follow his suggestions../

[Sunnyway 344]

The insurance company must tell you in writing why they are denying coverage for the WLS. Your BMI is high enough, so there must be another reason. You can (and should) challenge denials, up to and including "peer to peer" reviews during which your surgeon talks to a high level person at the insurance company. Every appeal takes it up a notch to someone with more knowledge and authority. You have alternatives if appeals fail. One is to complain to your state's Commissioner of Insurance.

[♡MyCurves 2]

My BMI is 47.3 but I don't have diabetes or other health problems does anyone know what I can do next to get approved ? If I don't get surgery and lose weight health problems could follow just don't understand why they wouldn't want to prevent them paying more money in long run . I am desperate ?? !!!

Well, if they're saying you need a comorbiditie, like diabetes, then unfortunately, that's what blood tests would have to show to be approved. That's what happened to me. I have Amerigroup, but I heard Molina is similar.. I was denied bc I didn't have that or debilitating joint issues (something to that effect)...I was pre diabetic when I submitted my paperwork. I retested and I found out I was in fact diabetic. I was approved quickly thereafter.

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