Question:
Has anyone had Humana PPO with an exclusion in policy for WLS ????

I have talked to acouple different employees with my ins . carrier and was told if surgery was medically necessary they would cover and one said it would not . How hard will this exclusion on the policy be to get approval ? I have all the pluses ... BMI , several comorbids , . I really need the surgery and want to proceed , also any recommendations on Dr. in San Antonio ?/    — patti G. (posted on November 30, 2002)

November 30, 2002
Hey Patti! I have Humana PPO and when I called the insurance company, they asked my height and weight and then put me on hold. When she came back, she said that I was eligible for the surgery. I don't know if your policy excludes WLS, but if you can find your policy booklet, there will be a written exclusion if you have one. For example, mine says, "Surgery or treatment for obesity not a covered benefit, unless classified as morbid obesity". So you see, it IS a covered benefit if you are morbidly obese(at least in my case). To be sure, just look in your book or call the insurance company yourself. Be sure to get names and extension numbers and your life will be a whole lot easier. Good luck!
   — Wendie G.

December 1, 2002
I have Humana PPO and called them before I went to my consultation. I was told by 4 different people that I was covered under my policy if I met the 100 lbs over weight which I do. But, after my surgeon sent in for approval I found out my policy has an exclusion. So I was denied. I have appealed and was denied again. I was told my the nurse that called me to tell me about my second denial that she has never seen Humana approve a case with a exclusion. Even with 2 appeals. Sorry to say I have not had surgery yet. Check your policy for exclusions. I know other people have been approved very quickly by Humana. I guess we just have the "cheap" policy that cost a lot!! Good Luck! P.S. I don't know if you have had Humana long but, I always get a different story from everyone I talk to about problems I have with them. It is very irriating to say the least.
   — kimmarie68

December 1, 2002
Patti, I was denied twice by my insurance company. It wasn't until I send the person who denied it a two page letter describing all the symptoms I had and they may be treating later that they agreed to pay for it. Please visit my profile and see my comments about the post surgery problems. Dan
   — Danny J.