Anyone else???

I just found out today that I will be attending the seminar with Dr. Shina on Tuesday, Nov 2 at 9am. Is anyone from this board gonna be there? I'm so very nervous and excited about it. I have been wanting...er...no, NEEDING this surgery for so long, and I hope this is the true beginning of my journey. If you are gonna be at this seminar, please let me know. It would be cool to meet face to face. Linda

Linda, Did you get Humana to approve your surgery? If so, how did you get around the exclusion? I just went to the doctor today and he recommended the surgery for me. He is going to write me a letter of medical necessity and send it to Humana. I called Humana and spoke with one of their supervisors and they stated that it wouldn't hurt to send it in. Please let me know of any helpful details that you can give me? Like how you got it approved? And how many times did you have to try? Let me know soon!!! This gives me hope!!!!

Hi Adrian - No, I didn't get Humana to approve the surgery, YET! When I called them originally about it, was told that there was an exclusion, whether medically necessary or not....but to have my PCP send in a LMN. So on Sept 25th, that's what I did. About 2 weeks later, I called Humana to check the status, and was told that it was in "medical review". On October 19th, I called again and was told that my case was NOT in medical review, that I had to get the hospital where the surgery would be performed to request the authorization. Well, I couldn't do that, cause I hadn't even been to see the surgeon yet, so the hospital didn't even know I was considering the surgery. So Margaret at Humana gave me her private # and told me to call her the next morning and she'd call around and find out what I needed to do. The next morning, I called her, and she called my PCP and told him that he needed to request the auths. He told her that since he wasn't doing the surgery, HE couldn't request the auths, so Margaret called Dr. Shina's office. Jeannette (I think was her name) told Margaret that with the exclusion, they wouldn't be able to request the auths, unless there was a chance that it would be covered. Margaret told Jeannette that IF it was medically necessary, it more than likely WOULD be covered, but that I HAD to have a consult with a surgeon before I could do anything else. So I had to call Dr. Shina's office to set up an appt. They are sending me the profile packet (should get it tomorrow or Wed) and I have to take the packet with me Tuesday. Once Dr. Shina determines if I'm a candidate for the surgery, they will submit my paperwork to the insurance. I have no idea if it will be covered, but, Margaret told me that I needed to try real hard to get this surgery done before the end of the year, because starting Jan. '05, Humana WILL NOT be covering it AT ALL. My advice to you is make an appt with Dr. Shina (if that's who you are going to) and attend the seminar on Tuesday, Nov 2 (if you can get in) and then have them file your paperwork. I can ONLY hope and PRAY that all goes well and that I'll be approved and have my surgery BEFORE the end of the year. Good luck, and please let me know if you will be attending the seminar. Linda

Linda, I am having St. Joseph resubmit my paperwork to Humana. They are basically requesting the authorization again for me. My PCP is writing me a letter of medical necessity and sending it to Humana. I know that I will probably be denied because of the exclusion, but I can appeal the decision and if they deny again, I can have the Kentucky Board of Insurance review my case. I was told by Mary at St. Joseph East, that they are good about overturning decisions by Humana. I really need this surgery because I can't keep the weight off. I can lose the weight, but I can't keep it off. Can you give me Margaret's phone number at Humana. I would really like to talk to her because you and I are in similar situations. We both have Humana and we BOTH need this surgery. We need to work together on this to get it approved. Do you know of any obesity lawyers around Central Kentucky? If I have to, I will threaten legal action against Humana. There has been really good results with people getting approvals when legal actions was threatened. Please give me Margaret's phone number and let's work together on this issue to get an approval. I have hypertension and Hyperglycemia. My doctor told me that I NEEDED this surgery for medical reasons. Please let me know. Thanks, Adrian

Adrian, Where is St. Josephs? Like I said, they told me that I had to have the hospital submit the auths, but since I never contacted them, they went to Shina. After I see him, he will submit the paper. I sent in the LMN that my PCP wrote, but it didn't do any good since I haven't seen the surgeon. I don't have Margaret's phone # anymore. It was on my caller ID, but I guess DH must have removed it. What I would do is call Humana, and ask the customer rep and talk to them. Tell them you know there is an exclusion, but that you were told to submit a LMN and now you don't know what to do. If I were going to contact a lawyer, I'd go to www.obesitylawyer.com and contact them. They charge between $295 and $495, depending on where you are in your process. Good luck and let me know if there's anything else I can do to help. Linda

Linda, The Center for Weight Loss Surgery at St. Joseph is in Lexington, Kentucky. I was really wanting margaret's number, so I would be able to converse with her. I have some hope, but not a whole lot. Do you know of any other lawyers in kentucky who would take on this type of case? Have you heard anything yet? Please let me know!!! Thanks, Adrian

I'll see if I can find the paper I wrote her # on, but I'm almost certain it went out with the trash. I don't know of any lawyers in KY, but the obesitylawyers.com lawyer is experienced with WLS cases, and usually has good results. No, I haven't heard anything, but don't expect to until at least 1 - 4 weeks AFTER my initial consult, which is not until next Tuesday. As soon as I hear something, I'll let ya know. Linda

Linda, Have you heard anything yet?

Hi Adrian Here's the posts I made on Tuesday and today about my situation. (11/02) Went to the consult today. I felt really good about this. Thought things were finally, FINALLY gonna go my way. WRONG! Got to the seminar at 8:45am. Waited till about 9:15, and the office staff came out, introduced themselves, told us what would happen while we were there, and then talked to us about their own experiences. Finally, after about 20 minutes of Q & A, one by one, they called us into the "office" to do the paperwork, exam, etc. Since DH and I were the first ones there, we were the first ones called back. So I paid my co-pay, had my picutre taken (what joy), signed all the necessary papers, then went back with the nurse (Glenda) to have the BP, temp, etc taken. As she was filling out some of the papers, she said, "Oh, you have Humana?". I said yes, and asked if there was a problem? She said "Hold on a second, they JUST changed their criteria". That made me really nervous. So here I am, sitting in this office, waiting to find out what was going on. So Glenda comes back and says, "Yep, as of LAST FRIDAY Humana now requires a 6 month supervised diet." OMG, I am so thoroughly pissed! Why you might ask? Well, Humana has decided that as of 01/05 they will no longer cover this surgery FOR ANY REASON, and in order for me to do a 6 mo supervised diet, I need another 6 months........which puts me completing that in April 05, about 5 months too long!!!! I don't see how they are allowed to do this, but there's nothing I can do about it. So, unfortunately, I have no hope of having this surgery. This was my last chance, and now it's over. I am upset, and sick, and have cried more than I ever thought possible, but I've exhausted all avenues, and there's nothing left for me to do but just accept it and move on. I have taken this as a sign that this surgery just isn't something I'm meant to have. (11/04) Hello everyone...hope you are all having a great day. Just wanted to update on my insurance situation. As you know, on Tuesday, I had my consult with the surgeon. Was told by the nurse that as of 10/22, my insurance co made it so that I now had to have a 6 mo dr supervised diet history. Not possible for me, since after 01/05, they will no longer cover this surgery, no matter what. So, Wednesday, I called the insur co to find out what exactly was going on. The first person I spoke with (Umeka) told me that there was NOTHING in my files showing that I was requesting pre-auths for gastric bypass. I told her that I KNOW that was BULL**** because previously, I was told that they received the LMN from my PCP on 10/08, and that 3 different times (10/11, 10/19, and 10/22) I had called and been told that it was in "medical review". She told me that she sees "notes" where I called, but that was all. She also said that she couldn't see anywhere that the requirements had changed and that the diet history was now required. GRRRRRR I told her what my surgeon's office had told me, and wanted to know why I wasn't 'grandfathered' in. She said there was "no reason" to grandfather me in, since the policy hadn't changed. She told me that she could transfer me to a "medical nurse" who could probably answer my questions. So, I was transfered and talked to the nurse (Becky). I asked her the same questions...HOW can the policy change without notice, why wasn't I grandfathered in? She stated that "to her knowledge there has been no change in the requirements". She asked me was it the surgeon's office that required the diet history, I told her no, they said it was Humana that changed it. Becky said that she has never heard of it changing. She also said that I needed to call the surgeon's office and have them call and get the pre-auths. I told her that the surgeon's office won't do ANYTHING until I get the diet history. She looked at the system, and then told me there was no 'pre-cert screen' (whatever that is?) for me, and that was going to be a problem, that without that, they couldn't do anything. So I told her I guess I'm screwed. She said no, she'll put in a bogus date, take my info (ht, wt, BMI, co-morbs, etc) and do a pre-cert screen on me. So she did. She told me that it usually takes 2 days, and that IF the benefits are in the policy, I could expect to hear something by the middle of next week, but IF there were no benefits (exclusion) then it would probably be immediately denied and I would probably hear something by Friday, Monday at the latest. She told me that I can appeal the denial and I asked her if I could still appeal it after 01/05 since I had already started the process before then. She said yes, I would be able to. So, now I wait for the denial, and then as my last hope, I guess I'll have to contact one of the obesity lawyers. aTake care, Linda

Linda, Any updates yet? Thanks, Adrian