Question on insurance denial

[animallover1247]

I had the sleeve a little over 2 years ago and I need a revision due to severe GERD. I have received two letters of denial from my insurance company. The reasons for denial are 1. Not medically necessary 2. Gastric bypass is only covered for weight loss, not GERD. I can likely get my surgeon to prove it's medically necessary but not sure how my surgeon would argue for a procedure that isn't covered by my policy. Does anyone have any advice or input regarding this problem?

[MikeMo]

Not totally sure what to say, I always figure if I'm a very bad person in this life, I'll find myself filing health insurance claims in hell. But I'll give it a shot.

My read of above is that they are trying to say GERD is not a condition which requires Gastric bypass. Which is a bit laughable, bypass is probably the main treatment for GERD from what I've read. If your doctor can argue that he's tried other treatments, medications, whatever to treat your condition, and that bypass is the only remaining option, that would address the medical necessity issue. But the second hoop, if you can prove medical necessity then they say they won't cover it is a stumper. I would like to think the exclusion is to force alternative treatments before considering it to be a medical necessity. In which case, addressing point one clears point two. Otherwise, ick!

Can you argue you need to lose more weight and that's why you're looking at the bypass?

One option, some companies out there have HR ombudspersons who will help with health care issues. Or perhaps an understanding HR manager might be able to help you out.

Hopefully others may have had this experience and know of a magic bullet solution. My policy flat out had a bariatric exclusion that shoved me into self pay. Worst case, it's possible you could find a economical self pay option, but that truly blows. Don't feel like I've helped much or any, but I understand your situation, and it's frustrating as heck.

[Christie13]

If your doctor can prove medical necessity I don't see why it wouldn't be covered but you never know.

[animallover1247]

Thank you for your response. I am currently maxed out on medication the insurance is paying out near $800/month for and it isn't even controlling the reflux. Unfortunately I cannot argue I need bypass for weight loss because I lost 90% of my excess weight with the sleeve. What really puts the icing on the cake is my insurance offers a service where they hire a company to look at my medical records and give an opinion as to what would be the most appropriate treatment. They had an "expert" in bariatrics to view my records/testing. He determined bypass would be my best (and only) option. However, the insurance didn't even take this report into account. They are the ones that paid for the **** consult! To say this is frustrating is an understatement. I hate insurance companies. I suppose they want to contiue to pay ridiculous amounts of money for medication and then chemo if I get cancer from the long term exposure to my esophagus from the acid reflux ��