Gastric Bypass surgery and insurance!!?

Question

My mother is in need of gastric bypass surgery. She works for the state and they have an exclusion in their policy that will not cover this medically necessary procedure. She has tried open enrollment to get with a different carrier, but it is an exclusion that the state puts in. Is there anything she can do to possibly get it covered? She cant afford the $25k out of pocket!

Answer 1

Ask the doctor and hospital for financial assistance is she is low income. They might write some of the expense off.

Answer 2

Do not listen to what anyone has responded so far, except mbcratz and zippy. The rest might mean well, but they gave horribly misleading responses.

Here's the deal - your mom's contract excludes gastric bypass. Unfortunately, it doesn't matter how much she needs it or what documentation the doctor sends in...when something is excluded from your policy, medical necessity is completely irrelevant.

Her doctor's office could send in all the documentation in the world to her insurance company's medical review department. The medical review deparment could look at it and say "yep, we agree 100%...she is a perfect candidate for gastric bypass based on her medical information." And it still wouldn't matter...exclusions are exclusions, period.

Forgive me if I sound blunt or harsh, but I just wanted to be very clear...some of the other answers are saying "oh, just have her doctor prove she needs it" and steering you in the wrong direction.

No matter how much she needs it and even if the insurance company agrees that, medically, she "needs" the surgery, it will never be covered under her policy. No way, no how. Exclusions are exclusions, period.

She has 2 options: 1) Save up the money and pay herself. or 2) Somehow convince her employer to stop excluding gastric bypass from their coverage options, which still wouldn't take effect until 2009 anyhow.

I hate to be the bearer of bad news, but unfortunately it is what it is.

Answer 3

If the procedure is explicitly excluded from coverage, it makes no difference if it is medically necessary or not. The policy simply doesn't cover it. It's not unusual for insurers to exclude certain high cost surgeries/treatments from coverage, as a means of keeping monthly insurance premiums more reasonable.

I don't mean to sound harsh here, but if gastric bypass will work for your mother, so will a strict diet on her part, combined with exercise. The net result of gastric bypass surgery is to limit the amount of nutrients absorbed by the intestine, along with limiting the amount of food intake. If she does this on her own without the surgery, she will undergo weight loss, without the potential complications from gastric bypass surgery.

Answer 4

If she is a GREAT candidate (classified as morbidly obese, more than 40% BMI) and her doctor is on board with her- What she can do is get him to write a letter of referal, why he believes she needs this surgery and why they should pay for it. Then she'll need to find a surgeon who does gastric bypass- get his opinion- have them write a 2nd letter to the insurance company about how much she needs this surgery. It's been done before. If your mother is in danger because of her weight, she should have no problem getting her doc/a surgeon to side with her and hound the hell out of the insurance company.

Also,
Have her consider LapBand. It's much much much more safe. Very NON-invasive and can be reversed if necessary. I know way too many people who are now miserable because nobody worked on the psychological aspects before the gastric bypass surgery. Not to mention how they can pretty much never enjoy food normally again. My friend wound up just about "anorexic" because she couldn't even eat an entire bag of M&M's- and she had a GREAT doctor.
LapBand can be adjusted, reversed and has better outcomes as well seminars on lifestyle changes to help the patients through hard times.

Good luck!

Answer 5

You can not force an insurance plan to pay for something they do not cover. 99% of insurance plans don't cover this kind of surgery because it's expensive. (If the patient is a candidate, they first have to lose 10% of their current body weight under medical supervision, THEN they have to have pre-op counseling, pre-op testing, the surgery with the hospital care, THEN the post-op care.) What you can do is try to prove medical necessity - by having the doctors provide written documentation showing that it would be livesaving surgery.

Otherwise, she's going to have to negotiate a payment plan with the doctors.

Answer 6

Nope. The exclusion is put in there by the state.

Plus, no private carrier is going to say, oh, sure, give us $500 and we'll pay out $25K. It doesn't work that way.

She is going to need to finance this on her own. Take out a second mortgage, sell the car, borrow from her 401k, whatever. If she really, really needs it, she'll find a way. $25,000 isn't that much. If families can find the $100,000 they need for heart transplants for their kids, she can find a way to do 1/4 of this.

Answer 7

unfortunately gastric by pass is still an elective surgery not a lot of insurances pay for those. you could check and see if her coverage includes reconstructive plastic surgery etc. then you might have to get doctors opinons saying it is a life saving procedure in the same vein as the reconstructive surgery. but i think its an up hill battle for you. those ins companies hate paying money they dont think they have to

Answer 8

To state the obvious, she could try healthier options like improving her eating and exercise habits so she doesn’t have to undergo this potentially dangerous surgery. Her insurance may cover nutrition lessons or have discounts with a gym, if they don’t have one onsite. Has she checked into these other options?

Answer 9

my mom just had this done as well.... (lfor medical reasons)..

too many people including ins carriers don't realize the medical reasons... diabetes, heart disease, hypertension...

if her doctor can prove that it's a medically necessary surgery, you can fight the insurance providers... my mom's insurance covered hers...

good luck!