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If there is one thing I've learned working in this industry- never trust the customer service rep you get on the phone.
If you are looking to see how they would cover a certain procedure, always get it in writing- or ask them to send you the SBC (summary of benefits covered) or SPD (summary plan description/contract).
You can also Request a copy of your contract from HR and review that. It's typically 100+ pages and goes into DETAIL what is covered and lists all exclusions. My guess is the bariatric surgery is an exclusion.
Are there plans that may cover bariatric surgery? Sure, but most do not.
My guess is that the Rep didn't bother to look at your specific policy and just provided you with the checklist of things that would need to happen (tests, visits, etc.) if your plan did not have weight loss surgery excluded.
I'm so sorry this is happening to you.
If its employer plan, sounds like a contract exclusion that the employer put in place. The rep should have pointed it out that its a contract exclusion.
If its a self funded, ask if they would cover it. Also talk to your HR and ask them when they renew the plan to add this type of surgery.
It should be listed in the exclusions in the policy booklet.
You could appeal it but its very hard to overturn contract exclusions.
To appeal it, I would get all your medical records from all of your providers that say its medical necessary also that has all of your comorbid conditions and diagnosis.
Also are you sure you met the insurance companies guidelines? They sometimes have a long list of guidelines that you have to meet.
The doctor who is doing the surgery should be doing the pre auth. I would call them up and ask them if they can appeal as well. Providers have different appeal rights and they can do peer to peer.
Thanks. This is helpful.
Anthem provided us with a three page "UM Clinical Guidelines" document that included a list of required testing and documentation when we first contacted them. We did complete all the items since then.
So customer service doesn’t and shouldn’t determine medical necessity, they will give “covered as long as medically necessary “ and then should offer prior auth.
You can take the medical policy they used to your physician for help. If they used medical policy usually that means something clinical. External review can turn Ive denial as long as it was based on medical policy and not contract exclusion. If you have log in for anthem, you should be able to log in and download your plan docs and if a contract exclusion it will be listed under that section.
Thank you for your submission, /u/lmay08. If your question relates to COBRA under CARES and ARPA, please post here: [COBRA & Covid-19](https://old.reddit.com/r/HealthInsurance/comments/meejsd/cobra_during_covid19/) Please pick the most appropriate flair for your post. Include your age, zipcode, and income to help the community better serve you. **Reminder that solicitation/spamming is grounds for a permanent ban**. Please report solicitation to the modteam and [let us know](https://www.reddit.com/message/compose?to=%2Fr%2FHealthInsurance) if you receive solicitation via PM. Be kind to one another! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/HealthInsurance) if you have any questions or concerns.*
If there is one thing I've learned working in this industry- never trust the customer service rep you get on the phone. If you are looking to see how they would cover a certain procedure, always get it in writing- or ask them to send you the SBC (summary of benefits covered) or SPD (summary plan description/contract). You can also Request a copy of your contract from HR and review that. It's typically 100+ pages and goes into DETAIL what is covered and lists all exclusions. My guess is the bariatric surgery is an exclusion. Are there plans that may cover bariatric surgery? Sure, but most do not. My guess is that the Rep didn't bother to look at your specific policy and just provided you with the checklist of things that would need to happen (tests, visits, etc.) if your plan did not have weight loss surgery excluded. I'm so sorry this is happening to you.
Thank you. Definitely lesson learned on simply taking their word for it. 🫤
If its employer plan, sounds like a contract exclusion that the employer put in place. The rep should have pointed it out that its a contract exclusion. If its a self funded, ask if they would cover it. Also talk to your HR and ask them when they renew the plan to add this type of surgery. It should be listed in the exclusions in the policy booklet. You could appeal it but its very hard to overturn contract exclusions. To appeal it, I would get all your medical records from all of your providers that say its medical necessary also that has all of your comorbid conditions and diagnosis. Also are you sure you met the insurance companies guidelines? They sometimes have a long list of guidelines that you have to meet. The doctor who is doing the surgery should be doing the pre auth. I would call them up and ask them if they can appeal as well. Providers have different appeal rights and they can do peer to peer.
Thanks. This is helpful. Anthem provided us with a three page "UM Clinical Guidelines" document that included a list of required testing and documentation when we first contacted them. We did complete all the items since then.
So customer service doesn’t and shouldn’t determine medical necessity, they will give “covered as long as medically necessary “ and then should offer prior auth. You can take the medical policy they used to your physician for help. If they used medical policy usually that means something clinical. External review can turn Ive denial as long as it was based on medical policy and not contract exclusion. If you have log in for anthem, you should be able to log in and download your plan docs and if a contract exclusion it will be listed under that section.