Question:
confused about wording of my policy
obesity surgery is under the exclusions section but as you read on it states unless med necessary, does this mean i have a chance of approval or is it hopeless, i have Cigna HMO and am waiting for approval. — roxxyblue72 (posted on January 10, 2003)
January 9, 2003
You may have another loophole if the policy says surgery for the treatment
of obesity. The WLS is for the treatment of MORBID obesity.
— John Rushton
January 9, 2003
"unless medically necessary" means that with this surgery, your
helth will improve, ie: comorbidities will get better. So, IF you have
comorbidities that will improve with weight loss, you have a good shot at
getting this covered.
— Vicki L.
January 9, 2003
My insurance says the same thing, and I called and they told me that they
will cover it if my PCP deems it medically necessary. Which basically means
if you have a doctor that considers you significantly overweight, with
enough commorbids,and is willing to give you a letter stating medical
necessity, you should be jusst fine. Call you insurance just to be sure.
— Laydie K.
January 10, 2003
i think most of our policies stated the same thing, but there is a
difference between obesity and MORBID obesity. As long as you are 100
pounds overweight and/or have a BMI of at least 40, you are MO. That
wording- obesity v/s morbid obesity is key! You definitely have a chance as
long as you are MO. Call your insurance company and ask them specifically
if they cover surgery for MO and what all they need for the approval
process. No matter what, DON'T GIVE UP! Fight, fight, fight! Best of
luck!...Karen (lap rny- 9/20/02- down 98 pounds!)
— karmiausnic
January 10, 2003
Usually "medically necessary" as used for this purpose is defined
in company policy, or actually in the insurance policy. If it is in the
insurance policy, continue reading the exclusion and see if there is a
definition section. If not, ask the company for a definition. <br>
According to the National Institutes for Health (in MD) and the MD and VA
mandates, weight loss surgery is "medically necessary" if the
individual is 100 pounds overweight, has a BMI of 40 or more, or has a BMI
of 35 or more with significant co-morbids (eg sleep apnea,GERD, Diabetes
Type II, heart disease). However, some insurance companies (writing
policies outside of MD and VA) simplify the definition to mean either a BMI
of 40 and/or being 100 pounds overweight. <br>
If you can get the definition of "medically necessary" from your
insurance plan, follow that definition in making the case that your surgery
is medically necessary. Use the terms used by the insurance plan, so that
even the lowest level employee can see you meet the definition. For
example, if the policy says "sleeping disorders" are comorbids,
and you have sleep apnea-- don't say just sleep apnea, but "sleeping
disorder, sleep apnea". <br>
Good luck!
— Beth S.
January 12, 2003
My insurance said the exact same thing. As long as my PCP determines it is
medically nessessary...I'm good. Tomorrow I go in for blood work to
determine if I have a metobolic disorder (Hyperthyroidism), diabetes, and
other stuff. After that, I think (GOD WILLING) my doctor will write his
letter of nessessity to the insurance company.
I'd call your insurance company, explain to them what you'd like to
do...ask them what they require of you for coverage. I'm sure they'll help
you out.
— Renee B.
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