DENIED PAYMENT BY INSURANCE BUT THEY SAY IT IS MEDICALLY NECESSARY...

Have you ever heard of this one? I was denied TWICE. After the first denial, I resubmitted with more evidence such as the MRIs and a letter from my orthopedic surgeon as well as the original one from my internist. The review board said it was medically necessary but they would not pay it as it was specifically "excluded coverage" on my policy. Also, any other major claim I have submitted such as a visit to the ER room, charges for two MRIs of my knees, etc. were all initially declined by HUMANA and I had to write letters, get copies of MRIS, etc and send in so they would pay those claims. Then they tried to say my clinic and drs werent in their network even though they were listed in their directory of providers for Humana Care Choice. I am 406 pounds with a BMI of 52. I am 6 foot tall. I have two areas of torn meniscus on the left with severe joint space narrowing of the knee with wear and tear and loss of joint space. On the right, I have a torn meniscus as well with decreased joint space and extensive swelling and soft tissue damage. I went in for surgery four weeks ago on my left knee, after I had been declined twice for weight loss surgery. My orthopedic surgeon said if I didn't have it repaired it would create more damage and eventually lead to total knee replacement. I was prepped and ready to go the operating room when the anesthesiologist said....STOP THE BUS! I was at extreme risk for surgery and he called the surgery off. I was so embarrassed and humiliated as I was told the surgery was cancelled due to my weight and the increased risk. My orthopedic surgeon would not call me back for days after this, as I guess he was embarrassed too. I called my insurance company raising tee total you know what. They said in order for me to have the surgeries on my knees that I would have to pay for the weight loss surgery myself as it was specifically excluded in my policy. Now, here I sit...I can't have the knee surgeries I need as the anesthesiologists fear for my life and want me to lose at least 100 pounds in the next few months so they can do the repair...I've been told to stay off my feet..... I can't lose weight on my own and stay off my feet......I am at a place now that I feel like I could just die. I am so short of breath that I sleep in a recliner at night. I need help and advice on what to do. I have been declined twice with Humana and they will not pursue it any further. HELP ! Anyone got any ideas.

Hi Tammy. I am sorry to hear about the problems with your knees. It seems like a catch 10. I can not believe they can not do anything for you with regard to your knees to at least help alleviate some of the pain - if even temporarily. As far as the weight loss surgery, I have never heard of anyone getting approved when it was "speficially excluded" from their insurance plan. It just doesn't happen. Regardless of how medically necessary it is. If it is excluded, then they just won't do it. I know that is not what you want to hear but that is unfortunatley the truth. People try to fight that exclusion everyday. You eith have to change insurance companies or self pay (which you can finance through certain companies). I really hope you are able to do what you need to in order to get your health problems under control. Don't give up. It is really important to stay on top of your health. Keep us updated and let us know if there is anything you need. Misty

Hi Tammy, Unfortunatly I m finding out myself. The exclusion means no. I am currently looking into purchasing other insurence on my own, and trying to find out which ones cover weightloss surgery. I don't know if you have aetna in Tn but here in Mass it looks the most promising to me. I had a surgery date of March 13th and now it is in limbo untill I figure out how to pay for it. I have bluecross blue shield of tennessee through my employer. (we are in Mass but the company is based in TN so our insurence is also from TN) I feel really bad for your situation. Keep updateing us. I had a similair expereince with another medical procedure being called off due to my weight. I know exactly how embaressing it is. I am really sorry you have gone through this. I also know how hard it is to lose wieight anyway; let alone while staying off your feet. You should check with your ortho dr and see if any exercise at all is allowed. Perhapes something like swimming or water aerobics might let you move abit while not putting too much stress on your knees???? It is something that was suggested to me by my doctor. Good luck!

I am so sorry! I was denied recently but it is not excluded in my plan. In fact my work has great covereage so I will pay barely anything. Did they say how they would expect you to lose an unreasonable amount of weight in that time? I am not sure where you are located but if you are close to Verizon Wireless at all they begin your benefits on day one. It is a call center, well there is more than one center in Tennessee. This is where I went because I knew I could get the surgery with them. I know that this may not help much but it is all I got. I am 416.6 and the two weeks ago I was denied had chest pain and found out I had a blood clot, not the first time either, and the emergency room doctor asked had I considered surgery and when I told him I was denied two days before... wow it has been almost two whole weeks! He was shocked and amazed and so was my PCP when he got to the emergency room. Keep ya head up and keeping asking for answers and solutions. If we can help in any way just ask.

the ignorance of the insurnace compaines just keeps on getting worse and worse. I mean there are folks out there that can benifit from this and cut down the rising cost of the insurances's costs but that makes no difference to them. I hope you are able to get this worked out in your favor.!

Tammy, First of all let me say to you: "DONT YOU EVER GIVE UP!!!!" I was denied twice, first for it being a policy exclusion.... and basically was left to fend for myself. I found out that they did have a certain critieria to meet for it to be deemed "medically necessary"... I met that, then they said that I had to have been on a medical supervised weight loss program!! I honestly believe that they keep knockin you down, just to see how much tenacity and perseverance you have! Well, they didnt realize that my nickname to some is "bulldog", and this meant my life! I was not about to give up.... and neither can you! After 3 months of going back and forth, calling, faxing... much much prayer... I finally got approval, and am scheduled for surgery on April 9th!! I dont begin to know every insurance companies and their quirks, but I know that in my own mind and soul, I could not leave one stone left unturned. One more phone call I had to make, one more fax that I had to send.... and most importantly, one more prayer to my Lord begging Him for help. I pray Tammy that you will get the stength that you need, and the hope that you have to have that one day you will be having your surgery!~ Please feel free to contact me any time... I am here for you. May God richly bless you in your journey is my prayer! Sonya