Insurance Company Letter of Determination
Excuse 2: Your Policy "Excludes" or "Limits" Coverage For This Procedure
If coverage was denied on this basis of “Exclusions” or “Limits” what the insurer is claiming here is that while the procedure might have been shown to be medically necessary in your case, your particular policy does not cover it. Experienced attorneys and insurance advocates know that the exclusions or limitations portion of insurance policies often present the most difficult obstacles to obtaining approval for bariatric surgery.
But there are ways for your advocate to fight back. Most courts require insurers to draft their exclusions and limitations clearly, conspicuously and unambiguously. If your advocate can convincingly argue that a particular exclusion is overly vague or subject to two or more meanings, your appeal may ultimately succeed.
Your advocate can fight a denial based on even a well-drafted exclusion or limitation by "going around" this obstacle. In some cases, while an insurer may exclude treatment for morbid obesity, a shrewd advocate can "build" a case for coverage of bariatric surgery as a treatment for the patient’s related co-morbid conditions (such as diabetes, hypertension, sleep apnea, etc.) So don’t give up. The fight isn’t over.
No Insurance or Policy Exclusions?
Deciding to have weight loss surgery is a very big decision and entails multiple steps before you enter the surgery center on operation day. One of the big steps to overcome is the reality of paying for the procedure.
One issue you must be prepared for is the cost of the surgery and how you are going to pay for it. In general, the costs associated with surgery can be thousands of dollars and includes:
- Hospital charges
- Surgeon's fee including laboratory tests and medications
- Anesthesiologist's fee
- X-Ray charges
- Consultant fees - as necessary
more on Insurance Company Letter of Determination
*TRICARE patients with authorization don't need a prepayment.
Copyright 2005
Professor Rudolf Weiner, MD
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