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Insurance Exclusion



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Problem - my surgery advocate finds that there is an exclusion for the surgery I want (VSG) in my health insurance policy. They say I should - 1) get a copy of the stated exclusion for bariatric surgery from the insurance company (which I should get in the mail this week), 2) contact my employer's HR department to find out if they'd be willing to make a one-time exception for me to have this medically necessary surgery, 3) ask my HR department if they have alternative health plans with coverage for bariatric surgery that I can switch to at my next benefit enrollment, and 4) use the self-pay option (NOT an option!). My PCP said he'd write a letter and/or contact the HR department and/or my insurance company to see what he can do for me. Does anyone have any suggestions?? Thanks in advance!

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Hello CarolynB,

I just experienced sort of the same thing with CIGNA! I was going thru the process of having the lapband and once the precertification paperwork was sent in Cigna denied me based an exclusion in our policy that specifically states in order for Bariatric surgery to be covered it has to be performed at a Certified Center Of Excellence. I was frustrated and I did 3 things: worked with my HR advocate, contacted the State of Fl Insurance Compliants and filed for an appeal and I wrote a formal letter of appeal and sent it into Cigna. It took about 3 weeks to her back for the state-still denied, it took 4 weeks her from my HR advocate to find another doctor (Which led me to the gastric sleeve) and about 6 weeks to hear from Cigna via my formal appeal. TO make a long story short I have now been approved to have any 3 of the procedures at any hospital in the state of FL. MORAL OF THE STORY don't give up! Something good will happen... Can't wait for you success story

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Thanks, Xavtay2!!

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I'm sorry to hear that you have to go through so many hoops to get it covered. How frustrating! I'm glad to hear Xavtay's story though. I'd follow their directions exactly and document everything you do, including the names of everyone you talk to. I find it's much easier to get things to go through insurance companies if I can provide some backup of who I talked to, what they said, and when. Good luck, I'll keep my fingers crossed for you!

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Thanks, Izuri!

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    • Alisa_S

      On day 4 of the 2 week liquid pre-op diet. Surgery scheduled for June 11th.
      Soooo I am coming to a realization
      of something and I'm not sure what to do about it. For years the only thing I've enjoyed is eating. We rarely do anything or go anywhere and if we do it always includes food. Family comes over? Big family dinner! Go camping? Food! Take a short ride or trip? Food! Holiday? Food! Go out of town for a Dr appointment? Food! When we go to a new town we don't look for any attractions, we look for restaurants we haven't been to. Heck, I look forward to getting off work because that means it's almost supper time. Now that I'm drinking these pre-op shakes for breakfast, lunch, and supper I have nothing to look forward to.  And once I have surgery on June 11th it'll be more of the same shakes. Even after pureed stage, soft food stage, and finally regular food stage, it's going to be a drastic change for the rest of my life. I'm giving up the one thing that really brings me joy. Eating. How do you cope with that? What do you do to fill that void? Wow. Now I'm sad.
      · 0 replies
      1. This update has no replies.
    • Alisa_S

      On day 4 of the 2 week liquid pre-op diet. Surgery scheduled for June 11th.
      Soooo I am coming to a realization
      of something and I'm not sure what to do about it. For years the only thing I've enjoyed is eating. We rarely do anything or go anywhere and if we do it always includes food. Family comes over? Big family dinner! Go camping? Food! Take a short ride or trip? Food! Holiday? Food! Go out of town for a Dr appointment? Food! When we go to a new town we don't look for any attractions, we look for restaurants we haven't been to. Heck, I look forward to getting off work because that means it's almost supper time. Now that I'm drinking these pre-op shakes for breakfast, lunch, and supper I have nothing to look forward to.  And once I have surgery on June 11th it'll be more of the same shakes. Even after pureed stage, soft food stage, and finally regular food stage, it's going to be a drastic change for the rest of my life. I'm giving up the one thing that really brings me joy. Eating. How do you cope with that? What do you do to fill that void? Wow. Now I'm sad.
      · 1 reply
      1. summerseeker

        Life as a big person had limited my life to what I knew I could manage to do each day. That was eat. I hadn't anything else to look forward to. So my eating choices were the best I could dream up. I planned the cooking in managable lots in my head and filled my day with and around it.

        Now I have a whole new big, bigger, biggest, best days ever. I am out there with those skinny people doing stuff i could never have dreamt of. Food is now an after thought. It doesn't consume my day. I still enjoy the good home cooked food but I eat smaller portions. I leave food on my plate when I am full. I can no longer hear my mother's voice saying eat it all up, ther are starving children in Africa who would want that!

        I still cook for family feasts, I love cooking. I still do holidays but I have changed from the All inclusive drinking and eating everything everyday kind to Self catering accommodation. This gives me the choice of cooking or eating out as I choose. I rarely drink anymore as I usually travel alone now and I feel I need to keep aware of my surroundings.

        I don't know at what point my life expanded, was it when I lost 100 pounds? Was it when I left my walking stick at home ? Was it when I said yes to an outing instead of finding an excuse to stay home ? i look back at my last five years and wonder how loosing weight has made such a difference. Be ready to amaze yourself.

        BTW, the liquid diet sucks, one more day and you are over the worst. You can do it.

    • CaseyP1011

      Officially here for a long time, not just a good time💪
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    • KimBaxleyWilson

      Three months and four days ago... I was in Costa Rica having a life changing surgery! Yesterday we had a followup visit with Dr. Esmeral via video chat and this morning my middle number changed.  I'm down 47lbs and two pants sizes. I can wear a Large tshirt for the first time in like... 14 years! Woot!! Everything is going great. I have zero regrets. I went down to the riverwalk with a friend and walked 2 miles on Monday without even getting fatigued. And no more snoring or chugging pickle juice for crazy leg cramps! I need to go to the gym more... I'm making new shirts next week so that will motivate me. LOL But I'm also just not as TIRED all the time! I have a LONG way to go...but seeing the progress on the scales and in the mirror is a huge motivator!! Thank you all for cheering me on and supporting me!!
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      https://alluniqueguide.com/java-burn-coffee-reviews/
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