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Having trouble with HUMANA (m)

Discussion in 'Insurance Issues' started by kkuncl, Mar 17, 2008.

  1. kkuncl

    kkuncl Approved members

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    I am trying to get approval for 2 CGMS, because both of my children have Type 1. We just switched insurance from BCBS (who paid for EVERYTHING) to Humana. The frustraing part is that we could have chosen UHC, who is currently covering CGMS.

    It is stated in our policy that we have coverage, but we keep getting stuck in pre-cert/pre-determination.

    The UHC and Humana policies are supposed to be the same...but clearly they are not.
     
  2. Jeff

    Jeff Founder, CWD

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    I spoke with someone yesterday who has Humana and has been told that Humana is not covering continuous sensors.

    We're waiting for approval for Marissa's sensor, and we too have Humana.
     
  3. kkuncl

    kkuncl Approved members

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    I met you yesterday!

    I was the woman sitting right in the front and mentioned that I have two children with diabetes.....

    Humana has told me that they cover the CGMS in our policy, but then they forward us to pre-cert and we get stuck. They claim that they have not received many different document, ie. medical need, etc. which we have sent MANY times.

    Anyway, I am working on from many angles and hoping to changing their mind.....soon.
     
    Last edited: Mar 17, 2008
  4. momtojess

    momtojess Approved members

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    We have humana, and we were denied, but it was because our dd is only 6, and they are fda approved for 7 and older. Our endo (at Cincinnati childrens) said they havent had any cgms approved by Humana yet.

    When I called Humana, they always claim to not have recieved stuff too.. then they told me last time that pre-determination will only accept stuff by mail, and not faxes any more.
     
  5. kkuncl

    kkuncl Approved members

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    Mail vs. fax

    We just heard the mail thing too.

    I haven't heard anything about my daughter's age...yet, but she will be 7 in May and my son is 9.

    I am definitely wishing that we had chosen UHC.
     
    Last edited: Mar 17, 2008
  6. momtojess

    momtojess Approved members

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    We got a denial (4 months after it was sent to them) saying it is considerend experimental because she is 6.

    The dr sent a request in january to let us borrow the guardian for a week, and that is the one Humana is now saying was never received.
     
  7. Connie

    Connie Approved members

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    We did get covered through Humana (in Cincinnati) last year. I had to go through the 3rd appeal through my employer to get covered. It was really my employer that agreed to cover it when Humana kept denying it.

    I had the same problem of them never receiving anything. I would ask for the customer service reps email address and send the information via an imaged file so I had proof they did get my information. It was extremely time consuming and frustrating but we did get our through.
     
  8. Connie

    Connie Approved members

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    My son goes to Cincinnati Children's and we have Humana and we are now covered.
     
  9. Jane

    Jane New Member

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    CGM denied again



    Connie, so did Humana finally cover it or your employer? We are at Cincinati Children's also and just got denied on round 2. I am not stopping there. I will appeal again.

    Thanks for any help
     
  10. Jane

    Jane New Member

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    appeal denied

    The reason that Humana has upheld the denial of CGM is it is "investiational" by that they mean : "that the medical communitiy and literature have not by consensus determined that sufficient evidence existis to suggest this is a medically necessary device for all patients with this patient's medical condition. Therefore, this device is considered "investigational" at this point and the member;s condition does not warrant the monitoring system"
     
  11. momtojess

    momtojess Approved members

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    If you child is under 7 that do have a leg to stand on with that statement, but if your child is over so, it isnt investigational anymore since it is approved by the FDA

    Talk to cincy, they will write an appeal for you also
     
  12. kkuncl

    kkuncl Approved members

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    Our Saga continues.....

    Humana has delayed and delayed saying that they didn't get our doctors stuff. Childrens has sent it 3 times via fax and once via mail. Last week, I got really mad and filed a complaint and now they have found everything....

    But, they have not made a decision. Last Wednesday after 2 hours on the phone they had to send to a Regional Medical Director to make the decision and he was supposed to take 72 hours. I called yesterday and the cases are still pending. I am giving them until Wednesday.

    I have been at this since January and I have not even gotten a denial yet. SO FRUSTRATING!
     
  13. momtojess

    momtojess Approved members

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    We started a trial run with the guardian last night. (no thanks to humana for ever approving it, we had to go through minimed, instead of through cincy). After just 10 hrs with the cgm, I am convinced we really need it!!

    I will be calling Humana today to ruffle some feathers.
     
  14. Connie

    Connie Approved members

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    We were covered in the 3rd appeal that went to my employer. Humana will not cover it but your employer is able to override the decision if they are self insured.
     
  15. Connie

    Connie Approved members

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    This is exactly what happened to us. We started the process in June and finally got the approval in October. I can't tell you how many phone calls I had to make to keep pushing. They always said they didn't have information and would find it once I made complaints to my employer.
     
  16. Connie

    Connie Approved members

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    We purchased the CGM and then went back for reimbursement because I really wanted this for my son. I used the information from the CGM to show the benefits. In my 3rd appeal, I showed what the first week was on the CGM and then how it got better after a couple of weeks. I told them in the appeal that even without evidence from clincal trials, I could prove the benefit this had for my son. The examples showed he never went low after the first week on the CGM.
     
  17. kkuncl

    kkuncl Approved members

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    Grrrrrr!!!!! We got our first denial! (m)

    I got so angry that I did complain to our employer, told Humana that I had filed a complaint and they suddenly found our paperwork. All along they kept telling me that we were covered, but they needed a letter from our doctor. Well, not the case. They denied it because they deem the CGMS experimental.

    I have decided to turn to our employer, because it should be covered, but because of the treatment that we were given and the treatment that our doctor's office was given.

    The whole process is SO FRUSTRATING! I have probably spent 20 hours on the phone with these people in the last 4 months, never mind the time that I have take gathering information and articles.
     
  18. Connie

    Connie Approved members

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    My employer wrote a special request to Humana and told them to cover it. Since my employer is self insured, they are really the ones paying for it in the end. My CGM supplies run through Humana and they cover it because my employer told them to. I never see a bill for this. It is covered at 100%..
     
  19. Jane

    Jane New Member

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    talked to Dave's employer..they were no help, said there was nothing they could do. I said "oh but there is more I can do; I will appeal to the Ohio Insurance Board" She told me to go ahead, it was my right. (yeah, I know my rights but this is a royal pain)
     
  20. momtojess

    momtojess Approved members

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    I never did appeal. We are in the process of purchasing one now, should have it by next week.. It will have enough sensors to get us through till Sept, when she turns 7, and then I will request for them to cover the sensors from then on. If they deny it again for experimental then I will appeal till the end. I will have the data from the cgm to show them
     

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