Re: Attn: RE: Exclusions

[Guest guest]

MomInSWFL@... wrote:

>

> In a message dated 8/20/2000 11:20:14 PM Eastern Daylight Time,

> lindat@... writes:

>

> << When there is an actual exclusion in your policy, it is faster and

> cheaper to change insurance than to sue them over it (and you usually

> haven't got much chance of winning in an exclusion situation, either).

> >>

>

> Here's a question..... I have my insurance handbook in front of me and under

> the 'Exclusions' segment, here's what it says about 'Obesity Treatment':

>

> " Exclusions

>

> The following are excluded from coverage:

>

> 27. Obesity Treatment, including but not limited to, surgical operations

> and medical procedures for the treatment of morbid obesity, unless determined

> to be Medically Necessary. "

>

> So does this mean I have a chance of them covering it?

YES! You have an *excellent* chance of them covering. The criteria for

" medically necessary " are usually the same as or similar to those set

out in the NIH standards.

" CLINICAL GUIDELINES ON THE IDENTIFICATION, EVALUATION, AND TREATMENT OF

OVERWEIGHT AND OBESITY IN ADULTS, The Evidence Report, " National

Institutes of Health, National Heart, Lung and Blood Institute, NIH

Publication No. 98-4083, September, 1998. Available in PDF Format at:

http://www.nhlbi.nih.gov/guidelines/obesity/ob_gdlns.htm

Short version:

BMI of 35 or greater, with co-morbidities

BMI of 40 or greater, no co-morbidities

[However, most insurance companies require co-morbidities and a lot of

documentaiton proving you have them]

Previous history of failed weight loss attempts (and the insurance

usually requires this to be well-documented, and to have had at least

one physician-supervised weight loss program in the past year for some

number of weeks, usually 12) <--- THE BETTER YOU DOCUMENT THESE PREVIOUS

WEIGHT LOSS ATTEMPTS ON YOUR PATIENT INFORMATION FORM, THE LESS LIKELY

YOU ARE TO GET HASSLED BY INSURANCE ON THIS POINT(since it is submitted

by Dr. Rutledge, so they often assume physician supervised weight loss

efforts because it is submitted by a doctor).

Co-morbidities, such as asthma, diabetes, hypertension, arthritis/joint

pain, edema of the face/fingers/legs/ankles/feet, high blood pressure,

high cholesteral, high triglycerides, fatigue, breathlessness (dypsnea)

on exertion, sleep apnea, gastric reflux disease (GERDS), Barrett's

esophagus (changes in epithelial cells in the throat from chronic

reflux), hygiene problems, fungus infections (under skin folds, for

example). <--- THE BETTER YOU DOCUMENT THESE PROBLEMS ON YOUR PATIENT

INFORMATION FORM, THE LESS LIKELY YOU ARE TO GET HASSLED BY INSURANCE ON

THIS REQUIREMENT (since it is submitted by Dr. Rutledge, so they often

assume physician documentation because it is submitted by a doctor).

Some insurance companies require a psychiatric clearance letter (saying

you are mentally stable to have the surgery and competent to make the

decision and capable of adjusting afterwards).

Some insurance companies require this or that, such as a TSH level

(hormone screen to see if you have a hormone imbalance).

Whatever they require, they will have a criteria/checklist, but they

WILL NOT TELL YOU what they require, so when you first send in

information to them, they will deny you and say it " isn't medically

necessary, " but what they are REALLY saying is that you didn't send them

everything they require (but they don't tell you what they require --

isn't this sick? And they ALL do this.)

About 80% of what I do helping people get insurance clearance is finding

out EXACTLY WHAT was missing to prove that the surgery is medically

necessary and then seeing that they get it.

> If they don't, I'll

> have to switch plans before I can go ahead with it... we don't have the $$ to

> finance a CAR, let alone pay for this surgery by ourselves....

>

> Robin

> Wife to Doug

> Mommy to Tyler, 4 yrs., and Brennan, 1 yr.

> Singer, wife, mom, secretary.. and not in that particular order.