Insurance question

Hi there,  I am curious if anyone has any problems getting an approval with health net PPO.  I  currently am doing all the pre op stuff that they are requiring and I received an EOB  from Health Net in the mail today stating the first visit to Dr Paya is not covered because "Services were rendered by a non -participating provider."  I of course tried to call them and they are not open today.  Has anyone ran into to at the final stages of the requirements, as I am on my last month of weight loss.. Any info would be greatly appreciated, as frustration is setting in.  Thanks..

I 2nd what Neely said!  The DS is probably the platium surgery out there now.  My Independent Medical Reviewer (IMR) agreed w/me against Kaiser,  through the Dept of Managed Health Care (DMHC).
 I also declined Kaiser's Option program (weight loss 6mo program).  Kaiser only does the RNY & band, and I was sent out of network to have the surgery with Dr John Rabkin in SF. 
My IMR decision:

MN08-7644
A 55-year-old female enrollee has requested laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) bariatric surgery for the treatment of her morbid obesity. Findings: The physician reviewer found that with a BMI of 39 and comorbid conditions this patient meets nationally accepted medical necessity criteria for consideration of weight loss surgery. Peer reviewed articles demonstrate superior weight loss and maintenance of weight loss over the long term with BPD/DS as compared to other surgical procedures. The published data also demonstrates that the Roux-en-Y procedure offers no advantage in regard to protein calorie malnutrition and may even have more severe consequences. This patient has significant metabolic syndrome, and BPD/DS is the treatment of choice for her obesity.

Sorry I dont have Healthnet PPO but I do have Healthnet HMO. They rocked...approved fast. Let me know if I can help ya.


Kitt

I just got approved via HeathNet PPO.

On my final approval letter, it said the Dr was out of network etc etc, which he is NOT.  I had their office call to verify too, and all is well.  Just make sure that whoever you see IS in the network.

Good luck!!