rejected because of exclusion... should I bother appealing?

[amanda2008 0]

I think I have a good case because I have so many other health issues caused by obesity. They rejected the request pretty quickly however.

Should I bother appealing? Has anyone successfully appealed and won?

[luluc 6]

If they have an exlusion clause against Weight Loss Surgery, I'm doubtful you can appeal (reason you had a fast reply). Not sure I've read where anyone was successful with that. I too was denied & then requested a copy of my policy (which I should have done first, rather than waste a few months of games), I clearly did not meet the criteria BCBS TX had for Bariatric Surgery - So I worked it so I could pay cash. If going self pay is an option - there are a lot of threads to give you help out here.

Sorry your going thru this!!

[amanda2008 0]

In the denial letter they said I could appeal. I was just wondering if it was a waste of time, or if anyone had ever successfully overcome an exclusion.

[luluc 6]

I"d say give it a try - Can't be in any worse of a spot than where your at now. Hopefully others will chime in - if they've been successful.

[Wheetsin 714]

It depends on the type of exclusion. One has been appealed successfully, the other really cannot be. Trying to make this simple, there are exlusions that your insurance company has, "no we won't offer this", and then there are exclusions that your employer has, "yes insurance offers this but we aren't paying for it". Which type do you have? Is there any terminology in your denial around plan exlcusion, employer-enforced exlcusion, etc.? If not, and you don't know, call your insurance company and ask them if it's excluded by them or by the employer.

[amanda2008 0]

I believe it is excluded by my employer. I asked them to add it and they said no because it would cost everybody more money, and they shouldn't have to pay more money for something only I wanted.

So my specific policy excludes it. HOWEVER I wish they would use their common sense to see that the surgery would prevent a lot of expenses that the company WOULD have to pay for it.

[CrueFan 0]

See Now Thats Just Crap. You Should Ask Them Wht Then Do You Have To Pay For Someones Hysterectomy Or Knee Surgery. If Thats The Case Why Cover And Surgery. I Am Going Through A Similiar Process With My Insurance And Knee Surgery. I Was Gonna Give Up ( After A Year And A Half Of Dealing With It ). My Ortho Told Me Not To Give Up With Them. Reason - The Insurance Companies Count On Ppl Giving Up. Then They Dont Have To Pay. He's Got A Point. Its The Squeeky Wheel Theory. Keep Fighting

[Wheetsin 714]

When it's an employer exclusion, you really can't do much other than asking your employer to cover it. There are more strategic ways of doing this than others, e.g. by appealing to that "common sense" (ROI) rather than just saying "please" but it really just boils down to their choice.

CrueFan - appealing her insurance will not get her anywhere when there's an employer exclusion. The insurance company owes her nothing because it has never been paid for WLS coverage. Her insurance company has never been paid for the WLS option, so of course they don't owe it to anyone, squeaky wheel or not. You can't have never paid for something, and then demand they give it to you for free. Employer exlcusions have NOTHING to do with them hoping you give up.

[MacMadame 81]

You need to get a copy of your insurance policy to find out the exact wording of the exclusion. Some people have policies that say WSL is excluded period and for those, you should only appeal if it's part of the process to get your company to hear your case. (I.E., if the appeals eventually go to the board at your company that approves exceptions). If your company doesn't do it that way, you need to use whatever method they do use to get your appeal to the right people.

But some policies say WLS is excluded unless medically necessary and in those cases, you can appeal and make a better case for being medically necessary and it will work.