Wisconsin Medical Necessity Laws

Hi, everyone. Does anyone know where I can go on-line to find a description of the WI Medical Necessity Laws. I have United HealthCare and the rep. for my employer told me that in WI it is a law that a procedure cannot be denied, even with an exclusion in the policy, if it is deemed "medically necessary". I have been trying to find this in writing from a state govt. web site so I have this as back up when I submit my paperwork for approval or appeal. If I do find it in writing, I'll post the info here for everyone. Thanks for your help! Happy Saturday!

I wonder if your able to retrieve that info from one of the local hosp library or call and ask if there is a site???? Its worth a try

Sorry Tracey. . . She DOES need back up and A LOT of it. It sounds like she has UHC through a private insurer, not Badgercare. Badgercare is a state-run Medicare program with it's own set of rules. Badgercare is administered through many different insurance companies in the state, UHC one of them, and Dean Care HMO is another, for example. Unfortunately, these HMO insurance companies will not pay for WLS even if it is medically necessary if it is a private or employer-paid insurance policy. They do have written exclusion policies. As unfair as it is, the Badgercare recipients are easily able to receive the surgery because of the fact it is a Medicare/Medicaid governed program with it's own rules. I know this for a fact because I used to have Dean Care HMO and was DENIED for surgery while others on Badgercare received the surgery via Dean Care. There was a woman who was approve surgery through Unity HMO because of the medical necessity. . . but she had to fight like hell and get an attorney. She was the first in the state. I will look for her posting and forward it to you Rachel. I believe she asked for an "independent review" hearing to determine if it was medically necessary, and if the Independent Review Board says it is medicall necessary, then the HMO has to pay for it regardless of the exclusion policy. Perhaps try the Office of the Insurance Commissioner for the State of Wisconsin and find out how to get the independent review. Good luck. E-mail me and let me know how it's going ([email protected])