Hi All,
Does anyone on this forum has UnitedhealthCare signature value HMO plan? Do you know whether or not it covers Ketamine infusion and SGB/LSB? Is it difficult to get the authorization?
I used to have BCBS PPO plan and i have the freedom to go to any doctors and i don't have any problems of getting the care so far. However, my employer only offer either Kaiser or Unitedhealthcare. I did not like Kaiser because i was not offer the care that i needed for my RSD. I was lucky at the time because i also had another PPO insurance. So if you can tell me about the Unitedhealthcare HMO, i truly appreciated your help.
Thanks.

Dear Numb,
You should be able to call the doctor's office that will be doing the procedure as they do it all the time and will know which ins they accept. You may want to ask for a manager in their office and make sure you get the name of that person you talked to (date and time can't hurt either). If they don't accept either one they may be able to refer you to another doctor who will accept it.
Good luck,
kathy d

I managed to get pre-authorization on my outpatient ketamine infusions in early 2010 from UHC in RI. But my coverage is not an HMO plan. I was initially denied and had to appeal multiple times. Since the plan was already covering the infusions of at least one other individual in the state, I knew that eventually I had a decent chance of prevailing - and I did win my appeal. But the amount that the plan paid was far less than what they agreed, and SIGNIFICANTLY less than what my doctor charged on a daily basis.

My case was a WC case, and I won my court case in early June 2010. Since then, WC has been paying for my infusions.

Check out the Ketamine Klub on FB for more info on dealing with insurance issues. Good luck to you!! Xoxo Sandy

Hi Numb,

I have been in the health care field for 23 years. I have seen many variations of HMO-style insurance companies. Incidentally, Kaiser is an HMO, the largest among them. Unfortunately, they mostly work the same in that you are sort of "sold" to the IPA or physician/group whom in turn are responsible for your case-care. Generally, the "group" gets a flat rate per month to handle your care. They get paid the same per month whether you go to the doc or not. So if you need more than the average Joe, you start to cost them money and consequently costly procedures will be denied. The "group" will have multiple reasons why it will be denied (i.e. standard of care, experimental, investigational) and will opt for the cheapest treatment approach possible which is usually delaying everything and placating you with palliative approaches (endless ibuprofen, for example). And when you get denied, the insurance company will have a toothless appeals process if you choose to persue it; perhaps even your state too. Since it is not fee-for-service and is capped, the standard is less quantity and quality of care so that more people may enjoy the same. It is truly a system of "less is more." This will also be the premise for pending single-payer system except there won't be an appeals process and the standard of care will be redefined to be that of cost-reduction, not based on quality of care and will decided on by the bean-counters, not the MD's. These are just my opinions only and based off of personal observations. There are of course, endless variations to the above and I am sure those who will tell you that their HMO is the cats meow!

Oh, and in terms of legal recourse, you can't sue an HMO (Knox-Keene Act)! Neat, eh?