Insurance Coverage

featherweather89

I'm starting to delve into what is required by the insurance company to get my sleeve surgery covered- and hit a bit of a road block. There's verbiage in my work's health insurance plan that says they do not cover any bariatric surgeries. I was advised to file for an appeal and was wondering if anyone else has had to do so. I also have a semi-unique situation, as mine would be done during my transplant surgery, and I am aware that Medicare actually DOES cover bariatric surgeries, but I have to do some research to see when I'm eligible for that, as I'm considered ESRD now, but I'm not on dialysis. Any insight? Thanks!

featherweather89

The benefit to having it done during transplant, is not having an extra hospital stay, and I'll already be opened up, so that part of the surgery would be combined with the need to transplant the liver.

rpyle111

My bariatric program has an insurance specialist who walks each patient through their own specific requirements. I did not know this was the case and didn't start the program until I had my insurance approval. The others in the program said that this lady knew every kind of insurance's ins and outs and guided them into the right appeal/test/etc. call your program and ask about your insurance's specifics. They probably have experience. Good luck with both surgeries!!!

Robin628

My employer had the same clause and I was unsuccessful on appeals. They put that clause in for a reason, they absolutely do not want pay for WLS and they don't have to. I ended up saving $ and taking out a loan to finance my VSG. I traveled and had my surgery in FL for $11K. It would have been $25K in my home state of CT. I could've had it done in Mexico for less than $5K but that scared me a bit. FL was a good compromise. There are also good lower cost facilities in TX and NV.

featherweather89

@Robin628 I wish that were an option! but given I only have 22% kidney function currently, I'll be sticking to the hospital I'm having my future transplants at. Might still take out a loan... we'll see where I get with Medicare I suppose. It's funny that some insurance plans are so against it, while in the end, they could be saving a significant amount more than is being spent on the surgery.

Robin628

Agreed! Good luck @featherweather89!

100poundstogo

@featherweather89 I am a week and a half post surgery. I had a lapband since 2011 and it did not go as well as I thought so I had it taken out and converted to the sleeve. My insurance covered it the first time and this time minus my co-pays and deductibles. I'm in FL also. My daughter wants and needs the surgery and her insurance does not cover it and she is in FL but its the type of coverage your employer chooses and they do go for the bare minimum...Fortunately enough for me I do have a very good insurance through my workplace---Aetna!! Good luck to you

featherweather89

Update: My insurance company failed to actually send me the form in the 7-10 business days. I called, and got it emailed. Now just waiting the allotted 30 days they have for a written decision.