I've been reading my EOC once again

[Susan in Tennessee]

trying to determine if complications, should they happen, would be covered under my policy or if they are excluded like WLS in general is. I'm sorry to say (well, not really, because I doubt I'm alone) that I have read my EOC about 20 times and I still don't know the answer to my question.

After all the reconstructive talk lately I was also looking at that section and from what I saw one section says "always excluded" but another paragraph says "usually excluded" so that leaves a slight crack open in the door, right?

Would it be possible for any of you insurance experts to give this doc a look and tell me what I have, in laymen's terms? It is online and looks to be the kind of document that can be emailed. Tell me how to go about sharing it with you. If I've asked something that isn't done or is frowned upon just tell me so, no problem. I am not meaning to take advantage of anyone's expertise beyond what is acceptable here and if this is, I apologize.

 

[Clematis]

Just put the paragraphs here that you showed me. That should be enough for the experts to weigh in.

 

[DianaCox]

Or post the link (if you don't have to be logged in to read it), or download it into a PDF and upload it here, so you can get multiple opinions! It's best to show the whole thing, because sometimes there are sections that contradict what seems to be plainly stated elsewhere. The sneaky bastids.

 

[Susan in Tennessee]

I do have to be logged in so I will see if I can do the latter suggestion. I might need assistance with that! . Sneaky is right, Diana!

 

[Susan in Tennessee]

Or post the link (if you don't have to be logged in to read it), or download it into a PDF and upload it here, so you can get multiple opinions! It's best to show the whole thing, because sometimes there are sections that contradict what seems to be plainly stated elsewhere. The sneaky bastids.

Diana, when you say upload it here, do you mean here in this thread or is there some place for document/files? And when you say all of it, you do mean ALL of it, right? :O

 

[DianaCox]

Here on this thread - see in the corner, the "Upload a File" button? Make a PDF of the document and upload it here.

 

[Susan in Tennessee]

Here on this thread - see in the corner, the "Upload a File" button? Make a PDF of the document and upload it here.

 

[DianaCox]

These are the relevant paragraphs I found:

Under exclusions, Attachment A:

V. Reconstructive Surgery
Medically Necessary and Appropriate Surgical Procedures intended to restore normal form or
function.

1. Covered Services

a. Surgery to correct significant defects from congenital causes (except where specifically
excluded), accidents or disfigurement from a disease state.
b. Reconstructive breast Surgery as a result of a mastectomy or partial mastectomy (other
than lumpectomy) including Surgery on the non‐diseased breast needed to establish
symmetry between the two breasts.​

2. Exclusions

a. Services, supplies or prosthetics primarily to improve appearance.
b. Surgeries to correct or repair the results of a prior Surgical Procedure, the primary purpose
of which was to improve appearance, and Surgeries to improve appearance following a prior
Surgical Procedure, even if that prior procedure was a Covered Service.
c. Surgeries and related services to change gender (transgender Surgery).
​

Under Other Exclusions, Attachment B:
This Policy does not provide benefits for the following services, supplies or charges:

27. Services considered Cosmetic, except when Medically Appropriate per medical policy. This
exclusion also applies to Surgeries to improve appearance following a prior Surgical Procedure,
even if that prior procedure was a Covered Service. Services that could be considered Cosmetic
include, but are not limited to, (1) keloid removal; (2) dermabrasion; (3) chemical peels; (4)
breast augmentation; (5) lipectomy; (6) laser resurfacing; (7) sclerotherapy injections, laser or
other treatment of spider veins and varicose veins; (8) rhinoplasty; (9)
panniculectomy/abdominoplasty; (10) Botulinum toxin;

28. Services that are always considered Cosmetic including, but not limited to, (1) removal of
tattoos; (2) facelifts; (3) body contouring or body modeling; (4) injections to smooth wrinkles;
(5) piercing ears or other body parts; (6) rhytidectomy or rhytidoplasty (Surgery for the removal
or elimination of wrinkles); (7) thighplasty; (8) brachioplasty;

29. Blepharoplasty and browplasty;

****

37. Services or supplies related to complications of Cosmetic procedures, complications of bariatric
Surgery; re‐operation of bariatric Surgery or body remodeling after weight loss;​

I think this is pretty clear - they will NOT cover complications.

 

[Susan in Tennessee]

Just wanted to hear it out of your mouth, thanks for taking a look. And this I pay $424.00 a month for with a $5,600 deductible!

 

[CaraOC]

Well that's a steaming pile of bovine excrement. I had better get a look at what mine says. Where do you get you EOC? I guess I could call them. I'm hoping I can get the belly remodeling after weight loss. I also want a face lift, a boob shortening, a thigh job and bat wings clipped. When all is tucked and shrunk I want a nice front teeth veneer. I'll be the new human Barbie!! Only 5"1 with the mouth of a sailor.

 

[DianaCox]

I'm sorry - my daughter has a Covered CA plan, and they wouldn't cover oocyte retrieval as part of her treatment for endometriosis, to preserve (not enhance) her fertility. There's a class action brewing, I hope.

@CaraOC - if you have insurance through your employer, you get your EOC from HR.

 

[Susan in Tennessee]

Well that's a steaming pile of bovine excrement. I had better get a look at what mine says. Where do you get you EOC? I guess I could call them. I'm hoping I can get the belly remodeling after weight loss. I also want a face lift, a boob shortening, a thigh job and bat wings clipped. When all is tucked and shrunk I want a nice front teeth veneer. I'll be the new human Barbie!! Only 5"1 with the mouth of a sailor.

You took the words right out of my mouth! We must have the same body! Poor thang. Are you seriously only 5'1"tall?? Oh, wait, me too!

 

[Susan in Tennessee]

I'm sorry - my daughter has a Covered CA plan, and they wouldn't cover oocyte retrieval as part of her treatment for endometriosis, to preserve (not enhance) her fertility. There's a class action brewing, I hope.

@CaraOC - if you have insurance through your employer, you get your EOC from HR.

Cara, does your insurance have anything online? Is there a portal for you to look up claims, etc? If so, your EOC might be available there too. I had to set mine up with a user/password etc. Definitely check out what they cover! I bet yours is better than mine, but that isn't saying much!