Selfpay due to denial-preop tests not covered

[jnkntrnk 0]

I'm writing on behalf of my friend, who was denied by her HMO for anything weightloss related despite the fact she has high blood pressure, etc.

She decided on the self-pay route and finally has the $ to pay.

Now she is trying to get her pre-op clearances and had an abnormal EKG; the cardiologist is putting the charges through on insurance but stating that the stress test, echo, etc., are in order to obtain weight loss clearance. Her HMO won't pay.

Does anyone have an idea on how to handle this? She obtained the necessary referral from PCP to Cardiolog; I think it should be covered since it's due to an abnormal EKG. She's trying to get the Cardio office to understand that she isn't even going to be able to have the surgery if she uses all her money on the pre-op tests due to insur decline.

Any thoughts I can pass on would be appreciated. I feel so sorry for her; my insurance approved -- we were hoping to go through bandland together.

:help:

[Candle 11]

Who does she have for insurance?

I had all my pre-op tests (including 2 EKG's, ECHO, and stress test) done a few months ago when I had a policy with Anthem BC/BS and they were all covered. I just had to pay co-pays.

There was a WLS surgery exclusion on my policy, so I've since switched to a different insurance company that does cover the Band.

[Candle 11]

PS. My old plan even covered my consult with my Lap Band surgeon. I was surprised by that. (All he does is Lap Band)

[Serena 0]

Jkntrk,

I was denied because of a WLS exclusion in my policy (but it was not an HMO) and, like your friend, I was referred for additional cardiac testing because of an abnormal EKG. My insurance did pay for those charges. The cardiac testing was done at a different hospital and perhaps they didn't connect the two, but I would think that an abnormal EKG requires further exploration that should be covered regardless of the reason for the initial EKG.

I think that the cardiologist's office should have billed it differently. I know that logic and potential long-term savings don't usually factor into insurance determinations, but if this further cardiac testing revealed a problem that early intervention could prevent or mitigate, the HMO would save big.

My heart turned out to be fine. I hope that the same is true for your friend.

[jnkntrnk 0]

Thanks, I agree this cardiac thing should be a no-brainer for them to cover; heck she could end up not being able to have the band if there's a real problem.

I think sometimes it's the young'uns in the office that talk out of turn.....

Will see....

Candle, I too have Anthem BCBS, with a WLS exclusion, but I was able to get my doctor to write a letter of necessity and was approved (woohoo). Moot point if you've changed.

Thanks for the advice!