When excluded doesn't mean excluded...

[MacMadame 81]

So after calling Aetna and talking to the CS rep and finding out that the lap-band surgery is excluded from my company's policy, I called our HR reps. The one I talked to said that WLS is excluded unless it's medically necessary. This is sort of what the Aetna rep said but the Aetna rep was coy about it and I got the impression that it was only if I went self-play and later had complications that the complications would be covered, not that I could make a case for the surgery to be covered from the start.

However, HR person said straight out that if my doctor can make a case for the surgery, they'll cover it. She said to use terms like "medically necessary" when my doctor calls for the pre-auth.

I also got the number for one of our other medical plans. I have a choice of 5 plans through 3 companies and thought maybe one of the others might cover it. But our UHC plan, which is what they call an "affinity" plan appears to be stricter than Aetna. They say they will only cover it in order to treat a second disease -- such as high blood pressure or Type 2 diabetes. This annoys me because it means they don't consider obesity a disease.

I suspect that my last choice -- Kaiser -- would definitely cover it, but I don't want to change my doctor and I'm not happy with Kaiser here in Northern CA. (I loved them when I lived in San Diego.)

Anyway, I'm posting this because I know there are a lot of people who have posted that their company excludes the surgery. If that's happened to you, you may want to push a little harder and see if they have that "unless medically necessary" clause and are just not being forthcoming about it.

[bradleybanana 1]

Thanks SO very much for the information. That gives me just a glimmer of hope that maybe my company will cover this. My Surgeon believes this is medically necessary even though I don't have the severe comorbidities that many other do. I see this more as preventing those things, and with my mom's help I'm hoping to put something together to show my company how much money they could actually save if they allowed this procedure. I have a meeting with the Benefits lady on Monday morning and I'm so very hoping that she'll give me something I can work with, even if it requires a 6 month diet and exercise plan I'll do it! To prove to them, that Diet and Exercise alone isn't beneficial to me in my situation. I need this tool to be successful in any type of weightloss.

Thanks again so much!

[MacMadame 81]

Often used to flimflam the unwary 'beneficiary' and confuse the issue.

Plus a bit of prejudice thrown in, IMO. The reps say things like "well, if you just want to lose some weight, it's not covered" as if thousands of people are getting WLS just for cosmetic reasons when all they really need to do is diet and exercise. They don't get it.

I am pretty sure I can get this approved if I get my ducks in a row, but even if I do, I am still thinking of writing to my company to explain how wrong-headed their basic policy is.

Don't get flustered. Each day take another step in the direction you want to go. Don't stop until you get someone that gives you the answer you want. Then take the next step.

Good advice. :w00t:

bradleybanana- I found the information here to be really helpful:

OAC * Obesity Action Coalition - “Working with Your Insurance Provider: A Guide to Seeking Weight-Loss Surgery”

[010308 0]

I don't want to be the one to burst anybodys bubble, but it's true that there are still many plans out there that still completely exclude WLS and any obesity treatment.

I suggest digging out the benefit booklet, dusting it off and opening it up to the exclusions section. If it says that all obesity treatment is excluded then it is likely they will not budge.