crying time again (warning, LONG)

I am soooo confused.... after all the work I did making sure I was covered for this surgery, calling the insurance company (HUMANA POS) 10 times if I called once, reading the policy certificate, seeing my primary, having blood drawn, going to orientation today for the surgeon, I have my surgeon appt tomorrow at cleveland clinic weston. Anyway... today while in line at the surgeons desk to get the packet for the psychiatrist, my phone beeps, seems dr szomstein's insurance lady called me. I ask for her at the desk, doesn't seem smart to use my minutes when i am standing there anyway... Anita, nice little lady she is comes out and proceeds to tell me that I am not covered for the surgery, it is excluded in our policy. I said how can that be, I have called numerous times, something must not be right. We went in the back and I called Humana, the person that answers the phone says yes, you are covered, just like any other surgery 100% if medically necessary, so I ask her about this exclusion thing that Anita is talking about, she isn't sure, she talks to Anita, then she tells me, she is going to have to look into this, as it is in one place saying it is covered under benefits, then it is also listed under exclusions, in the same policy. so... she is going to look into it and call me back. Seems she said they always look at the coverage, but never at the exclusions. SOOOOOO... i come home, save my policy which is a pdf file on their website to a cd, and hunt it, reading all 103 pages, and again I see on page 22 that it is covered, and on page 42 it is excluded. I called humana yet again, said I can not keep waiting, I have to find out what is going on, i have a dr appt tomorrow with the surgeon, they will not submit anything to the insurance company unless I have paid the $300 psychiatric fee and I will not pay that until I know for sure it is going to be covered cause I can not afford to put out that kind fo money for nothing. I was then given a phone number that the dr office has to call to speak to case management once the dr decides medically necessary. I called Anita back to tell her, and she says that is the normal claims number, ugh,.... I called that number myself, spoke to an agent, who saw what I saw, included and excluded, then she transfered me to a supervisor, who agreed with me, included, then was just as puzzled as everyone else, she spoke to yet another person in claims, who actually does the approvals and was told... the inclusion will supercede the exclusion, as long as the doc says medically necessary... so HERE I GO AGAIN.... I am not sure about this $300 for the psych consult, i am going to find out why I can not use a psych that is on our plan for this, why it has to be theres, as I really do not have $300 for this at this time. I was hoping to have surgery before the new year, in case his work does not offer humana next year, then i would have to start over with a new company. Please someone convince me this rollercoaster is really a good thing, I can't stand rollercoasters and I feel like my life is one right now. LeeAnn

LeeAnn, I am not sure about Point of Service type of insurance you have but I have military ins. which is serviced with Humana. Do you have a primary doctor *****quests from your insurance company a visit for bariatric specialist? In my case primary is the one whom determines if surgery is medically necessary not the surgeon. I had to have my primary write a letter of medical necessity to the surgeon I choose and thats where it all began after I attended the first mandatory seminars required by my surgeon. Surgeon told me his pre testing certifications I needed. If you need your primary dr to get referrals for you prior to dr visits then go that route. Tell him who you are seeing and ask for a referral and letter of medical necessity. Ins. won't come right out and tell you. My insurance didn't, I had to figure it out and make sure I had every test, past diet history, reports all in order. I also had to see my primary once a month for six months and have it documented as that is what was a priority with my coverage. One good thing is that its listed you have coverage but they will deny if you don't follow they protocol but I don't think they offer the details. Good luck I know you must be annoyed.

i did see my primary on Friday of last week, she is the one that set me up for seeing the surgeon today. Humana knew i was seeing my primary, and actually changed my primary 2 weeks ago so that I could get a referral for this surgery. I just feel like i am getting the run around, emotions are up and down right now like crazy, but my appt is in 2 hours so we will see. i do not have 6 months of supervised diets, however I do have 15 years of dieting history, my problem is i only go to the dr when I have to, so I really don't go very often, and for 2 years we had no medical insurance, so i didn't go at all.

dON'T GIVE UP. I have Humana( tri care prime) and I was aproved after first letter becaus it was med. necessary. So hang in there and keep your head up. I do know that they want a 6 month supervised (diet) weight documentation. That is a must. do you have that? Cyndee

So I went to my appt today, and what we have discovered is that in the policy it states it covers the surgery, but in the exclusions it says OBESITY, not MORBID OBESITY. My bmi is 42, and doc said yes, medically necessary. The surgeon was great, and his assistant was very attentive to my questions. They have my diet history chart for the past 15 years, and they are going to submit that along with everything else. I have my psych consult tomorrow morning at 9am, and nutritionist next week, then Nov 8 and 9 I have my other consults and my EKG, Chest Xray, Pulmonary Function, and upper GI/ small bowel series. i am tentative december surgery is what they wrote in my chart, if we can get this all approved once all my tests are done on the 9th of november. YAHOOOO... once again this may be a reality.

Leeann, Sounds like you are back on track, yippee! So many of us had bumps in the road with our approvals, tests or surgeons. Heck, some even had approvals cleared, dates set and then their surgeons (or clinics) stopped performing surgery. It's all a lesson in dealing with patience and insurance red tape. Stay positive and focused and I promise, it will happen for you too ! Amy

Leeann, Happy to hear all went well with surgeron, do you like him? Didn't you say you drove the Cleveland Clinic here in Naples or is there another near Davies which I have no idea where Davies is? ' You got all those test to keep you busy, and I was happy to hear you all ready t0 be teste and a tenative date, good job girl! He accepted your history thats kewl. Wishing you all the best. Keep us posted.

Leeann, sounds like your appointment went better than you anticipated. I am preop too, so I know the frustration that can be encountered. I hope things go smoothly for you from this point forward. Good Luck!! Betti

LeeAnn, Hang in there lady and I wish you good luck on your journey. I am also just starting this journey. Kathy

LeeAnn, feel free to check out my profile and borrow either or both of the letters on there for your doctor to send in and for you to send on your own behalf at the time your file is sent to the insurance company. It couldn't hurt!!!! Keeping good thoughts for you, Jan