Appealing Insurance with an Exclusion

I'm new here...I'm hoping to have DS as soon as my insurance company (Humana PPO) acts right!! I've already had my consult, done my psych evaluation, sleep study, pulmonary clearance, and done all my paperwork like lists of diets, etc. I AM READY! One problem, my insurance has denied me. They took about 3 days to decide they are not going to cover the surgery. I'm so frustrated. They said it's because of an exclusion in my policy. As of 9/1/03, they changed their policy to say no surgeries are covered to reduce obesity - PERIOD - NO EXCEPTIONS. First of all, I know there are some out there who've been approved by my insurance since 9/01/03. I've already looked it up! I'm appealing the denial, of course, but I want to know if there's anyone that has been approved after appealing, and the denial was because of an exclusion to their policy. How easy is it to get them to change their minds when there's an exclusion in the policy initially? I've written a big 5 page appeal letter, and I'm sending it in this week with all my doctor's notes, results, etc. Please let me know if you guys think I still have hope... Thanks! Robin

Hey Robin, I don't have any advice for you I just saw your post on here & wanted to wish you some good luck! I have a consult scheduled May 18th w/Dr. Husted & I will only have the DS. I know that my insurance covers weight loss surgery but I'm not sure about the DS specifically. My sister keeps telling me to just call & ask them but I am terrified that they are going to say they don't cover it, so I'm just going to wait for my consult. Well, hope to hear good new from you soon! Candi

Hi Robin, I had to deal with a denial (and direct exclusions are tough from what I gather but sounds like you may have some basis) but was forunate enough to have an opportunity to change jobs and get new insurance. I can totally understand your frustration. Sounds like you have the best battle plan. Hang in there and don't let them try and derail you. I think often times that they bank on people giving up as it's a meticulous process! In terms of policies, I learned the hard way that even the same policy may have different coverage depending on the company itself. Best of luck and we'll all keep positive thoughts for you!