Question:
Exclusions Overturned????

Can anyone give me advise on how to get a company written exclusion overturned? I know people have done it, so how? The insurance will allow me to do it in-network but not out-of network and the surgery I want is only done by Surgeons out of network. Any Ideas??????????? I have United Healthcare Choice Plus of Texas Thanks!!!!!!    — [Anonymous] (posted on October 24, 2001)

October 24, 2001
You can get this overturned; but, it all depends on they type of surgery you are having and why you must have it done by an out-of-network provider. If it's simply a matter of personal choice. If you want a particular surgeon who isn't in-network, you'll have to pay higher deductibles and co-pays. If your insurer will only allow one type of wls..like Rny...by an in-network provider. The only way to get around that is to argue that type of surgery you want is medically necessary and that no surgeon within your network does it. This happened to me 4 years ago. I wanted an endoscopic rny; but, none of the in-network surgeons did endo's. I need maximum benefits from my insurer; I didn't have the out-of-pocket money to go out-of-network. I also didn't want to delay my surgery by arguing with my insurer. I had the open procedure and used money to buy a health club membership.
   — [Anonymous]

October 26, 2001
Makin' a guess here--you want DS but they want RNY. Check out the mailing list at http://groups.yahoo.com/group/DS-Insurance_Authorization_Problems. Lots of ideas and help! Chris
   — Chris T.