Has anyone won approval for surgery with an exclusion on their contract? I have Humana...

All, If anyone has won approval for surgery with an exclusion on their contract, please let me know. I have been denied on the first attempt, but I am going to appeal it. I currently have a friend that I work with who has been denied on her first attempt and on her appeal. She submitted to the Kentucky Board of Insurace and it is currently in external review. She hasn't heard anything back yet. I could use some helpful information about this. I need this surgery and my doctor has told me that it is medically necessary. I just wish that insurance companies would cover this surgery. It would save them money in the long run. I will hire a lawyer and file suit against Humana if I have to, but I don't want to because I am not the richest person in the world. Please let me know of any helpful information. Thanks, Adrian

Adrian, I have Anthem Access of KY which has an exclusion. I am also under external review with the KY Dept of Insurance and am waiting on their decision. Please fight this till the end and do not give up. It is tough at times, but prepare for the worst and hope for the best. I will not quit fighting until all measures are exhausted. Good luck! Beth

It seems like when i was doing my research for my appeal, that an "HMO" has to pay for something that is medically necessary. My suggestion?? Write a KILLER appeal letter (i have one i used i'm always willing to share) and do some research on HMO laws. IF you have a letter from a doctor stating it's medically necessary, I am pretty sure they HAVE to cover it.... but in the past year since I've had to fight insurance, i'm sure the rules are changing. However, regardless, fight them! Feel free to email me and i'll send you copy of my appeal letter. Several people have used it as a template and gotten approved after denial. REgardless, hang in there!

April, Can you tell me where to start researching the HMO laws? Can you tell who to contact who might know the HMO laws? Also, can you email your letter? Thanks for the reply!! This gives me some hope. I have a friend who has her case in external review by the KY Insurance Board. She hasn't heard anything yet, but it has been a while. I will fight the insurance to the end because my wife had the surgery and it has greatly benefited her in many ways. Any information would be very helpful. If I find out that they have to pay by LAW, I will nail their butts in the water. Thanks, Adrian