Ins. denied approval for surgery

I have to say I've been very thankful for this group. So far I have been just reading all the information that you have posted on this list.

I was should be having surgery 12-23-02. But thanks to the good ole' ins. co that seems to know me better than my gyn that I have went to since I was 15yrs old. It's been denied and they want me to try 3 mo of BC pills.
I'm now 35yrs, have spent years with painful periods, horrible pms headaches...the bit.
I had my tubes tied after my youngest was delivered. Since then I have had very bad back pain that had often put me in the ER
(right around period time). After severe pains last year my gyn did laproscopic surgery to remove cyst on my ovaries and to try and repair my tipped uterus. When he went in he discovered Endo. which really suprised him. I had some relief for a few months it seemed. But now, I'm bleeding heavier, longer, more cramping and very large clots. He suggested a hyst as I have uterine fibroid also thus he didn't give me hormones to try and control the endo.

I had myself mental prepared for surgery. My house is VERY clean now and my family was ready to step up to the plate and take over the household cleaning. I had 3 weeks off from work over the christmas break. I'm a college student and work in a learning center so the timing was well thought out. Only to be screwed up by the lovely ole' ins. I filed an appeal, but they say it can take up to 30 days. Which really causes problems in the time off work.
My DR. is going to call them tomorrow and hopefully give them a piece of his mind as they are obviously missing part of theirs.
Wish me luck

Gina

~~ Oh Gina ~~

GOOD LUCK I'm cherring for you!! I hope the
gives them a HUGH piece of his mind! They deserve it. Well, they say everything happens for a reason. So keep your chin up and be patient (like you have any choise?). Your time will come.

We're here for you anytime. Keep us informed to what's happening. Try to have a wonderful holiday and remember all the other things in your life you have to be thankful for.

Best Wishes - :hiya:
Melissa

Unbelievable! That would be almost enough to push me over the edge and my problems don't sound quite as severe as yours and not nearly the number of years. Sometimes seems like we're being treated by the insurance companies rather than the Drs!

I hope you are able to post tomorrow and tell us that your Dr. was able to straighten them out.

Wish you the best!

Lucy

and convince insurance to approve. You mentioned your long term doc, but have you taken your records, test results and all that to another doc? Two medical opinions is better than one.

BCP is only a short-term solution to endo, insurance company should know that. The GRNH agonist like Lupron, also short term but around a grand a month. Hmm, pay six months of lupron or pay for the hyster?

I would also check into the appeals process with insurance. They may have not reviewed your med records and will have a more favorable response once they do.

How maddening. Do insurance companies think we can just stop working any 'ole time we feel like it?! So now you can take 3 mo of BC pills and end up having the exact same surgery at a more inconvenient time?? :-P

Hang in there, and good luck with that appeal :-)

Holly

P.S. -- my neighbor has had some success controling endo pain and bleeding by taking BC pills without a break (no period). You may want to find out about taking them that way, as it could offer you more relief.

(((Gina))),

How awful for you! Try to stay calm, though. I had the same thing happen when I needed some dental work done. It was denied until the dentist appealed and gave additional info. After that, things went along just fine.

It can be maddening!! Hang in there!

Oh Gina, I really feel for you!!!!!! Especially since I'm a teacher and know exactly what you mean about scheduling the surgery and getting everything lined up for the Christmas break from school. I had my TAH/BSO on Dec. 18 and it looks like I'll be good to go when school resumes in January!

I don't think insurance companies understand women's health issues AT ALL! I'm lucky -- Blue Cross/Blue Shield didn't second-guess my doctor at all. EVERYONE I've talked to who's had a hyst. has reported there were even MORE problems found in there during surgery than initially suspected and seen. In my case, I was having the hyst. for excessive bleeding and embedded fibroids. When he went in there, he found endo, adhesions, a very enlarged uterus, many cysts on both ovaries, adeno and, basically, organs "stuck together."

I hope your doctor does battle for you!!!! You'll be in my prayers!

s
Julie-Anne

Well, I just got off the phone with my gyn's office. My Dr. is MAD!!!
The ins. co. answer is to have me try Lupron first before they will think about okaying my surgery. Apparently this is a more expensive way and only short term ifx if any at all. HELP!!

hard day today dealing with my own gyn and getting home in a snowstorm frayed my last nerve just a little.

Lupron is not without side effects and my opinion, I don't think an insurance company has a right to dictate a patient must use a course of treatment that has harsh side effects. It also isn't cheap or a long-term fix.

For right now, all I can think of is a battalion of surgeons rendering medical opinions that the surgery is going to bring you lasting relief. Have the denials from insurance been given to you directly in writing? That is a requirement and they can't just use the doc as the middle person on that. I would also do a google search for your state looking for a regulatory agency that handles insurance claims from a consumer advocate viewpoint. I know IL has one and someone mentioned she is fighting thru a similar department in OK.

The other thing I would do is be sure your doc has your ER records, documenting that you were in so much pain that you needed emergency care. Might make the appeal he is making more powerful. Hospital records department can help you obtain these records.

Best I can do off the top of my head. With severe pain, severe endo and fibroids, there should not be any problem proving medical necessity and that conservative treatment is not in the patient's best interest.

Are you bleeding now? If so and it is severe a trip to the ER might be what the ins co. needs to say yes. Call and check with your dr. first.

It is so awful that someone behind a desk can tell you what is right for you when they don't even know who you are. I would like to see how some of these people who regulate us, have these conditions and be told NO. Just how would they react?