Beyond Confused

Margo · June 23, 2005

I am so confused and frustrated....

I have been waiting for approval from my insurance company. I was told all the paperwork was in and waiting for review. Then just a day ago was told that my PCP had to call and speak with a nurse to get pre-cerification for the surgery. Today I call to check and my insurance contact's line is busy so I thought I would talk to the person I got...she tells me that my policy excludes all WLS for any reason and I will not be approved...period. So I ask her why I am going through all this jazz if my insurance will not cover it...she said she did not know and repeated that it would not be covered....PERIOD!

What the hell is going on? Has anyone had the same situation and actually been approved? Am I wasting my time and going nuts for nothing? Should I just self-pay?

Please I need some sound advice....I can't stand this anymore....it's driving me crazy...I can't concentrate on anything but getting this approval. HELP

Margo

Mita · June 23, 2005

Has your Doc's office dealt with your type of insurance before?? Usually they will tell you first if your Insurace does not cover it.. I would call the Contact line and ask again. Don't settle!!

Can you touch base with your PCP and see what was the outcome of the phone call he made??

I am sorry you have to go through this... Hang in there.

soonergirl · June 23, 2005

You should have been given an "insurance certificate of coverage". In this, it will outline all of your benefits as covered by your plan. Skip everything and go straight to limitations and exclusions (every policy has them).

WLS should be listed under this section if they do not cover it, or if there are any specific stipulations around it.

I have told so many people this in other posts - but remember, that in many cases - the choice as to whether or not to cover WLS as a part of your policy is your employer not the insurance company.

If you can't find you COC - you should be able to get a new copy of it from your employer.

Margo · June 23, 2005

Thanks for the advice ladies....the confusion lies in that everyone tells me something different.

My surgeon's office is absolutely no help.

The insurance company people tell me, "no, it is not cover, period" and in the next call, "well, it is probably icovered if deemed a medical necessity".

My PCP is going to call the insurance co. and give them a pre-certification and talk to "the" nurse. (This is above and beyond the wonderful letter he already wrote and the complied medical notes he made available -- really sweet doctor!)

I would like to know what the self-pay cost is so so I get a feel for how to pay myself if needed, but my surgeons office will not discuss cost unless I make an appointment with the nurse to specifically talk about cost???!!! WTF is that?

I feel like my already sky-rocketing blood pressure is going to hit the roof.....

Margo