Re: Insurance Coverage/Donna

October 18, 2001

Donna,

They tried many things.. First they said that the surgery I needed was

denied for out of network. (there was no in network surgeon).. I

proved that my policy allows for out of network coverage if specific

services were not avail in network. Then they denied me that DS was

not a covered procedure.. I appealed two more times and showed where

in my policy the DS was covered. They tried to offer me the RNY as

comparible. Oh dont even get me started about how 'comparible' it is.

(NOT) Since Im the one that has to live with it the rest of my life, I

stressed that it was MY decision, not theirs since they already cover

WLS. They still denied me, so I took the matter to my statewide

provider assistance office. We had a formal hearing under oath where

their doctor showed up and there was representatives from the

insurance commissioners office and UHC supervisor via video

conference. The supervisor lied all the way through saying that they

stopped approving the procedure in Feb (I was initially denied for the

first time prior to that in Jan.) for lack of evidence that it was a

safe procedure (yeah RIGHT!! Im doing GREAT!!). Since my initial

attempt was prior to that, it should have been a moot point just on

that basis.. then I showed they continued to approve other clients

after this. The state asked them for proof they stopped approving in

Feb, but I gave them my proof that they had approved others anyway. I

flat out called them liars in the conference and my evidence

substantiated it. I won easily. I still have a case worker to refer

to if they dont pay every dime they are billed for. I hope I answered

your question..

Love,

Sue

> > > Does anyone know if United Health care POS covers DS surgery?

> > >

> > > Dr Macura

> > > Pre op

> >

>

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