confusion

Hi i am kinda new here. So i contacted my insurance company and they informed me that as of January 29th 2012 they no longer have any guidelines it only had to be medically necessary i have spoken to 6 reps and they all told me the same thing, so when i told the lady that is over the insurance info at the surgeons office she argues with me. Have anyone ever had this problem?

That office may not be aware of new guidelines that take effect after the first of the year.  You might try giving that insurance phone number of document (however the insurance co. informed you) so they can be aware of this issue.  If you have something in writing, give a copy to your surgeon.  DAVE

I deal a good bit with health insurance and "medically necessary" is a VERY loose term.  Your surgeons office may be making sure they create a good case for medical necessity before submitting to insurance.  Just a thought.

Okay, get out the written copy of what you have from your insurance company. If you do not have a copy, go to the website that handles your insurance and download a copy. (Employers can pay for different things so it's important to have the same copy as your HR dept would have).

Then take a COPY of that to your surgeon's office. They may be looking at the 'one size fits all" policy requirements from xyz insurance and your employer may make it easier/harder than xyz does. The surgeon needs to go by YOUR insurance policy criteria not xyz's insurance criteria. XYZ is a way of saying BCBS/UHC/Aetna/Etc...whatever policy you are on.

Liz

They probably haven't received official notice of this yet.  Trust me, the office people at the surgeons tend to think they are the end all be all of knowledge, but they are not.  Make sure that the hoops are not a requirement of the surgeon instead of insurance.  Some surgeons have this.  Otherwise, just respectfully insist that the package be submitted as-is and you will deal with the requirements if the response includes any.  I had to do this with my surgeon's staff when they argued that I needed a 6 month diet and my insurance said otherwise.  Of course, she never admitted that she was wrong, but I know I was right and took my surgery date happily without saying another word.

sounds to me like you only have to have comorbidities,sleep apnea,PCOS,GERD,etc to qualify. and no 6 month diet or anything. Any or all of those conditions would make it "medically necessary",but ur DR has to state it in those terms"medically necessary".

GL