(Closed) Surgery deemed "medically unnecessary" by insurance?!

posted 5 years ago in Wellness
Post # 3
Member
11343 posts
Sugar Beekeeper
  • Wedding: May 2009

@peasantsong:  I am so sorry to hear this.  I definitely would contact your doctor’s office first thing Monday morning to inform them of this decision. Perhaps they will be able to contact your insurance company to provide additional supporting documents and medical justification for this procedure.

Post # 4
Member
4035 posts
Honey bee

@peasantsong:  Not a doctor, lawyer or insurance specialist here, but I would recommend contacting your doctor first thing on Monday morning! You need to either clear up the issue with your insurance first or be prepared to pay the full bill. Fighting claims after a procedure is really difficult and drawn out.

There may have been an issue with how the procedure codes were processed or your doctor may have to explain it to the insurance company why it is needed. In the end, your insurance could still decide not cover it (which unfortunately happens more than it should).

ETA: This happened to me recently when I was arranging to have my Mirena IUD re-inserted. My clinic sent me a bill for $500 before the procedure saying my insurance would not cover the full cost. However, I had spoke with the insurance company and they said that because of Obamacare reform, Mirena was completely free. I had to call my clinic and have them re-file my claim with different codes, then it came back as free.

Post # 5
Member
14496 posts
Honey Beekeeper
  • Wedding: June 2011

This usually happens when the insurance companies doctors or nurses looks over the case. Your doctor should know about the appeals process, usually involving letters and further med records. I have helped several of my dads clients through the process. It could also be attributed to miss coding something, so make sure you doctors office goes over the submission for coding errors. Sorry you have to go through it, I know it is a real pain in the rear, but I am afraid you will prob see more of this in the future.

Post # 7
Member
4035 posts
Honey bee

@peasantsong:  Not sure if they can get it that fast, but it is possible. My appeal took two days, but it was also more of a routine procedure.

Unfoturnately, this is the world of privatized healthcare. This happens a lot and there are many tragic cases where individuals have been denied life saving services and procedures because a company has denied them.

I had a co-worker (when I worked at an AIDS organization) that has HIV and needs about 15 different medications to maintain a somewhat comfortable lifestyle. His insurance said that 5 of the medications were not medically necessary. He had to pay $1200 a month out-of-pocket for the medications. Without the medications his t-count would drop so low, he would likely die much sooner. It really is a tragedy what American insurance companies get away with these days.

Post # 8
Member
14496 posts
Honey Beekeeper
  • Wedding: June 2011

 

I dont know if you can get it done by Friday, talking to a supervisor at the insurance company might help.  Some will go the extra steps and walk you through it or call the doctor themselves and get it worked out. I know our insurance company does.  Good luck, I hope you feel better soon and get this worked out.

Post # 9
Member
4960 posts
Honey bee
  • Wedding: August 2013

Graves disease? I would appeal. Emphasize that this is your doctors opinion, or get the opinion of a specialist if you can, like an endcocrinoligist. 

Post # 11
Member
4960 posts
Honey bee
  • Wedding: August 2013

@peasantsong:  Yikes my dear. I’m sorry you are going through this obscene nonsense while you’re ill. I’m not sure what else to do other than appeal. I know people who have gone through irradiation and eventual removal of the thyroid. I’m a hashimoto’s patient. All I can think of is to appeal to the insurance company. 

Post # 12
Member
11752 posts
Sugar Beekeeper
  • Wedding: November 1999

@peasantsong:  it is likely an auto response when they see that X procedure is scheduled without having tried Y and Z first. 

Call your doctor first thing Monday morning.  They can probably speak with the insurance company to prove the procedure is medically necessary.  Don’t worry about it for now. I definitely would reschedule the procedure if it’s not taken care of beforehand though. It’s much harder to get reimbursed after the fact. 

Post # 13
Member
1830 posts
Buzzing bee
  • Wedding: November 2014

Your doctor just needs to provide the insurance company with reason why this treatment is needed and the regular hierarchy of treatment (RAIU) can’t or shouldn’t be followed.

We get the same thing in the pharmacy with insurances. It’s called a Prior Authorization when the doctor has to contact the insurance and say “Yes, the patient really does need THIS medication” versus some other standard therapy (ex. a newer nasal steroid versus an older one).

I hope that you can get it figured out before your surgery. 🙂

Post # 14
Member
3626 posts
Sugar bee
  • Wedding: September 2012

I work in a doctor’s office, and this happens all the time. Just fax your doctor the letter with the steps for appealing the decision (though they probably received one too). They’ll know what to do. They’ll probably fax over your medical records supporting why the procedure is medically necessary. If the decision isn’t overturned at that time, your doctor will probably do a peer-to-peer review, where they speak with a doctor from the insurance company to discuss your case. Don’t worry! They can even appeal the decision after the surgery, as well, if it comes to that. Good luck!

Post # 15
Member
2321 posts
Buzzing bee
  • Wedding: July 2011

Talk to the doctor ASAP!!!!! And regardless of what happens, please get the surgery. Your life is more important than money. I would not be able to afford it too if I were in your situation but I wouldn’t want to risk my life either. It’s a VERY tough decision. I am sure your doctor will sort this out. Good luck!

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