Retired State Employee Denied

Hello all,

I've posted to this site before to check on my fellow homies to see how people are doing.  I currently live in Maryland and am almost 2 yrs post op.

My sister lives in Louisiana and is a retired state employee; however, the states health insurance is through Humana and they will not cover it -- and man would it benefit her to have the surgery -- yep -all the co-morbidities plus she needs a knee replacement --- why but an old body on a new knee -- sort of speak.

So question is -- does anyone on here have this wonderful insurance and was finally approved -- if so could you let me know how.

My sister is visiting with me in Maryland for the next couple of weeks while I'm recovering from a hysterectomy and I'd like to see what can be done to get her approved for the surgery.  Sp if any one has had or have this state insurance carrier and can offer any suggestions -- lemme know.

i am a current state employee and can tell you that every year approving the surgery is visited and every year it is denied.  There is a general exclusion written into the policy.  Years ago some were approved but no longer.  About 5 years ago they did a study to see the benefits - I applied to be a candidate of the study and never heard from them.  I had the surgery, but it was out of pocket.  I know several state employees who had the surgery and fought the insurance company only to fail and pay out of pocket.  I don't see the state paying for anytime soon given that not only would lots of employees jump on the opportunity, but those who have paid out of pocket rattle that if the surgery is every approved they will file a class action suit against the state for the previous denials.  Not a pretty situation!!!

I guess not.  However, if they want to reduce state expenditures surrounding Medicare and Medicaid -- some lawmaker may need to take up the fight -- if you all can find -- that is willing to state that in the long run it would be finanically feasible to include it as a benefit.  The state is costing itself money.  State lawmakers shouldn't want to be the state where 64% of it's adult population is obese and I'm sure a large number of them are state employees or retired employees.

I guess they are of the mindset -- so many others -- that a change a diet and increase in exercise will do the trick for everyone -- if it did -- everyone would be doing it.

I live in MD and they have law on the books that any company employing more than 50 people must carry the coverage. 

My sister has not been denied in writing -- only verbally and that was only because when she was suppose to go for a consult the surgeons office called her insurance and they told the office it wasn't covered so she never went for the consult so she was never denied -- formally in writing.

I've told her when she get's back to Louisiana that we need a formal denial inorder to lodge an appeal.  I'm looking at some things from my end to see if there is some kind of loop hole -- there has to be.

Thanks for your response - I really appreciate it.

I live in Lafayette, LA and Paid out of pocket (not a state employee though) If she can afford it I went to Dr Borland in New Iberia and it was only $9,300 total for a sleeve.  I am really impressed with him and would recommend him to my mother.

I am a state employee also.  I have OGB (Humana) but also  have insurance through my husband's company.  State Group will not pay for the surgery.  I agree that they are costing themselves money and  have several  co-workers who would  benefit from the surgery-to  no  avail.  We just keep hoping  things will change soon.  Sorry

State group employee and I had to self pay.  It specifically states that all WLS is excluded.  Yes, they are definitely hurting themselves by taking this stance.  One heart attack or stroke by far surmounts the $15,000 for most surgeries.  Even if they would only cover it at 50% it would make things so much easier for everyone.