If it doesn't support the patient there is nothing anyone can do. Otter estimated his group has been successful in 65 to 75 percent of its cases. Some are specifically excluded. Assuming something is covered can lead major financial difficulties if it is not. The most common mistake patients make is believing a treatment they happen to want is in the contract, when in fact it is clearly excluded, said Jim Godfrey, president of HealthGuard of Lancaster, a health maintenance organization serving six counties in south-central Pennsylvania.
Exclusions vary by contract, but there are some generally excluded treatments.
Some of the more common exclusions include nursing home care, infertility treatments, outpatient mental health care, hearing aids, eyeglasses, and routine vision and dental care. Personal improvement treatments are generally excluded, including treatments for cosmetic surgery done primarily to improve appearance, weight-reduction, enhancing athletic performance, erectile disorder, hair loss, and corneal surgery to correct refractive errors. Managed care trims costs by arranging contracts with doctors and hospitals for a specific cost. Going somewhere else will cost more, and the managed care company won't pay for it. Again, it's a matter of knowing how your insurance plan works.