Has anyone fought an exclusion? - ThinnerTimes

aselby04 · 02-19-2008, 08:25 AM

My doctor has referred me to a bariatric surgeon and I'm going next month to attend my first seminar for the surgery. I have insurance through Cigna and I called last week and they told me that there is an exclusion in my plan that doesn't cover any treatment for obesity. Has anyone had to deal with an issue like this?? If so, is there any chance in changing this?

VanessaSFL · 02-19-2008, 08:35 AM

I don't understand all the insurance stuff but wanted to welcome you to the forum.Some one will chime in here with some thoughts on your situation.

Again, Welcome

Zenomia · 02-19-2008, 08:37 AM

I know several people here have fought rejections, I am not sure though about exclusions. You might want to PM BarronPatrick, and ask him. He fought for a very long time and won. Wish I could offer more, but I just don't recall everyone. Did you try searching under, 'exclusions, denied, etc'?

Best of Luck..and Welcome!

aselby04 · 02-19-2008, 08:41 AM

Thanks for the replies and the nice welcome! I have done tons of research and I've yet to find any info where people have been denied by Cigna because of an exclusion. That's where I'm confused at. I called the company and they just flat told me that they don't cover obesity treatment and that's all the explanation they gave me. I'm going to have to call back I guess and see if I'm just getting the run around or is this somthing that my employer has opted for. I'm afraid that is going to be the case and I'm sure if it is, then I have no chance at all of winning.

bebop · 02-19-2008, 03:43 PM

my daughter and her hubby had cigna and that was in their policy. no weight loss stuff covered.
I have bcbs and my husbands company excluded it also. I did call them about it and they said no way would they cover it. that is as far as I took it though.

LyndasRoom · 02-19-2008, 03:46 PM

Hi and welcome...many times the denial of obesity treatment also carries the additional sentence of (unless medically necessary). Try to get some help with the interpretation of your insurance policy...and push, push push...

fisher1000 · 02-19-2008, 05:14 PM

Quote:

Originally Posted by aselby04

Thanks for the replies and the nice welcome! I have done tons of research and I've yet to find any info where people have been denied by Cigna because of an exclusion. That's where I'm confused at. I called the company and they just flat told me that they don't cover obesity treatment and that's all the explanation they gave me. I'm going to have to call back I guess and see if I'm just getting the run around or is this somthing that my employer has opted for. I'm afraid that is going to be the case and I'm sure if it is, then I have no chance at all of winning.

According to several recent news reports, GBS is being used as a current treatment for diabetes. Do you have that as a comorbidity? If you're doctor phrased things the right way, maybe you can get around the exclusion that way.

Here are some links to recent news items just for your info:
Article One
Article Two (from the Thinner Times website...)
Article Three

Hope this helps!

-Mike

SueRN · 02-21-2008, 10:14 AM

If your insurance policy excludes obesity treatment/surgery, there is nothing you can do on the insurance end. It's not about a medical necessity issue, it's a benefit issue. I work for BCBSNC. There are still a few employers that choose to not pick that up as part of the coverage they buy for their employees. Having said that, you may try to deal with the plan administrator for your company. Get LOMN(letters of medical necessity) from your MDs, health records, etc, to see if they can make an exception or possible change their minds to add WLS to their benefit package. You may even need to get an attorney. If something is denied for not meeting the criteria per the medical policy, it's easier to fight this, because everyone has an opinion, than to fight a benefit issue. You can't fight something you don't have. Good luck, Sue

annie's mom · 02-21-2008, 10:22 AM

Hi Sue,
I work for BCBS of Md. and am currently waiting for approval...How long did you wait and were you approved the 1st time...

We do cover Bariatric weight loss surgery ...

Annie's mom - Susan

aselby04 · 02-21-2008, 10:37 AM

Thanks for the articles Mike. This is what my plan states (word-for-word):

Medical and surgical services, inital and repeat, inteded for the treatment or control of obesity, including clinically severe (morbid) obesity, including: medical and surgical services to alter appearances or physical changes that are the reslut of any surgery performed for the management of obesity or clinically severe (morbid) obesity; and weight loss programs or treatments, whether prescribed or recommended by a phusician or under medical supervision.

But this clause states that they won't cover the surgery to treat obesity. I wonder if I could challenge it because I need the surgery not just for the weight loss but for the treatment of diabetes, chronic back, leg, and knee pain, and sleep apnea?? Could this be a loop-hole for me?