Exclusions in my Policy

[JayinMA 1]

The only thing I could find in the exclusions of my policy (I have harvard pilgrim PPO) was:

• Commercial diet plans or weight loss programs and any services in connection with such plans or programs
  

Does that mean I wouldn't be covered for lap band?

[*slim* 2]

The only thing I could find in the exclusions of my policy (I have harvard pilgrim PPO) was:

• Commercial diet plans or weight loss programs and any services in connection with such plans or programs
  

Does that mean I wouldn't be covered for lap band?

When they exclude WLS they usually spell it out saying that any type of WLS is not covered. What you quoted is usally for things like Weight Watchers, LA Weight Loss, etc.. If you can't find anything that specifically mentions WLS (mentioned as adjustable gastric banding and gastric bypass) then they probably have special qualifications. They won't list everything that they cover, but they will list what they don't. Call them and ask. Ask for it to be broken down and emailed to you. I emailed my insurance company, and they sent me a complete list of requirements for surgery. Good luck to you.

[JayinMA 1]

When they exclude WLS they usually spell it out saying that any type of WLS is not covered. What you quoted is usally for things like Weight Watchers, LA Weight Loss, etc.. If you can't find anything that specifically mentions WLS (mentioned as adjustable gastric banding and gastric bypass) then they probably have special qualifications. They won't list everything that they cover, but they will list what they don't. Call them and ask. Ask for it to be broken down and emailed to you. I emailed my insurance company, and they sent me a complete list of requirements for surgery. Good luck to you.

Thank you so much, I will send them an e-mail and ask if they cover it!

[*slim* 2]

No problem. My policy basically said the same thing that yours said. We can never know for sure until we ask! I hope everything turns out right for you! :biggrin:

[JayinMA 1]

Thanks, I was confused because the plan does offer a discount on weight watchers registration so it seemed contradictory but the e-mail has been sent and it was incredibly easy to find a list of weight loss surgery locations. So hopefully that'll be a good sign.

[JayinMA 1]

This is what I received as a response, I'm so new to insurance things however, that I'm not sure what it really means.

Thank you for your inquiry via the Harvard Pilgrim Health Care (HPHC) Secure Website regarding your coverage for bariatric surgeries such as the lap-band procedure. I would like to provide you with the following information.

Bariatric surgeries are surgical procedures that are intended to assist morbidly obese patients in achieving medically significant long-term weight loss.

Harvard Pilgrim covers bariatric surgeries that are Medically Necessary for morbidly obese members with documented history of failure to lose weight despite physician-supervised medical/dietary therapies. The following services are covered when specific medical necessity criteria are met.

• Gastric Bypass (Roux-en-Y)

• Gastric Stapling

• Vertical Banded Gastroplasty (VBG)

• Laparoscopic adjustable silicone gastric banding (Lap Band)

• Laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS)

Comprehensive multi-disciplinary program including:

• Pre-operative medical and behavioral health evaluation

• Medically necessary surgery

• Post-operative follow-up including nutritional and exercise counseling

Prior authorization is required for all bariatric surgeries. Clinical information must be reviewed by HPHC before services are authorized. Your physician will need to contact HPHC to begin the authorization process and provide our Medical Management Unit with all of your clinical criteria so that it may be reviewed for Medical Necessity.

If services are approved, per your schedule of benefits, member responsibility for Inpatient and Day Surgery services when performed at a facility recognized by Harvard Pilgrim as a Weight Loss Surgery Center of Excellence would be subject to a $300.00 copayment per admission when using a Participating Provider.

Services must be performed at facility recognized by Harvard Pilgrim as a Weight Loss Surgery Center of Excellence in order to be covered. The following is a list of facilities recognized by HPHC as a Weight Loss Surgery Center of Excellence:

Massachusetts

• Baystate Medical Center

• Berkshire Medical Center

• Beth Israel Deaconess Medical Center (BIDMC)

• Brigham and Women’s Hospital

• Boston Medical Center

• Caritas Norwood

• Caritas St. Elizabeth’s Medical Center

• Emerson Hospital

• Faulkner Hospital

• Lahey Clinic Medical Center

• Lawrence Memorial Hospital

• Lowell General Hospital

• Massachusetts General Hospital

• Mercy Hospital

• Newton Wellesley Hospital

• North Shore Medical Center – Salem Hospital

• Southcoast Hospital Group – Tobey Hospital

• Tufts – New England Medical Center

• U Mass Medical Center

• Winchester Hospital

Maine

• Eastern Maine Medical Center

• Maine Medical Center

Rhode Island

• Roger Williams Medical Center

New Hampshire

• Portsmouth Regional Hospital

Please note coverage for services is based on the patient’s eligibility and plan provisions in effect at the time services are rendered.

[Bostonlady 0]

Jay, did you get approved? I have Harvard Vanguard PPO and I was told that Harvard is one of the easiest with the least hurdles