Insurance is saying bariatric surgery not covered after 6 months of prep classes and a surgery date.. Lindstrom Obesity Advocacy?

3 posts in this topic

We have a situation, where my wife has gone through bariatric surgery prep work.. was told by the physicians office that she should be covered if she met criteria for the surgery.. even now had a scheduled surgery date.. only to find out now that the insurance wont pay for the surgery, because bariatric surgery is not covered under any circumstance.. its an unreal situation after months of classes/pscyh evals copays and visits to find this out.

I dont think this was the reason, but my employer changed ppo levels to a lower deductible / higher premium which changed insurance policies as of 11/1/2016.. much of the prep work and meetings began around oct time frame.

The insurance (UPMC) certainly did not degrade in coverages.  

Whats strange is that the office wont call in the appeal themselves.. she had to now call the medical card number and verbally state the appeal.. they claim they dug into phone records (only phone calls) and said no one ever said it would be covered (dr office phone records), however the in person visits told a different story.

At this point it feels hopeless and out of reach.. i'm not sure if a place like this advocacy lawyer could even help.. i've read it costs around $600, but if they win i suppose a small price to pay.


Any thoughts/experiences?

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My daughter was the insurance expert in the bariatric program at Mass General Hospital for a few years. Its was her job to get people approved, both for their benefit as well as the hospital. Mass General is a 1A certified bariatric center off excellence, and even though I had my surgery at a different stoop rated Boston hospital, their program also had an insurance expert and hat person was the first one to speak during indoctrination.

Check further, you may well have resources that don't involve legal action, and good luck!

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To echo what Tom wrote, I suggest that ASAP you reach out to your surgeon's weight loss surgery office to see if the person there who handles the office's insurance claims can help you.

I am an attorney who practices (among other things) insurance coverage law. It is very possible that when your health insurance changed that some coverages were dropped - including perhaps coverage for weight loss surgery.  Usually such dropped coverages are not mentioned since so few people use them.  

I am skeptical that any $600 service will be able to help you.  If the surgeon's office cannot help, you still may get coverage if you keep calling the insurance company, appeal within the company, and (if necessary) complain in writing to your state's insurance department or attorney general's office.

Be sure to be very active on this now, as the upcoming repeal of Obamacare (or the ACA) in the next few days/weeks/months almost certainly will result in less coverage for many health conditions in the future.

Finally, if both of you work for different employers then you should see if you can get health insurance that covers weight loss surgery from the other employer. 

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