Pre-certification DENIED by Insurance Company

As I sit here with a headache leftover from menstrual migraine the Doctors office called to tell me that the Inxurance company is rejecting the TAH BSO which is scheduled in 10 days. I have scheduled my entire work and summer family schedule around this surgery. I had several abnormal paps and I went through all of the procedures and surgeries to remove the bad cells. Now after you have these removed and have three clean checks over 6 mos. time it is safe to perform the hyst-because there is no risk of having cancer in there when they open you for surgery. So now that I did all of the procedures the Insurance company says there is no need for the hyst. because I had a clean pap smear. So I should just wait to see if the abnormal cells(CANCER) comes back or not. This is not a risk that I am willing to take-I may not be so fortunate next time to catch it in time-before it turns into full blown cancer. Besides the fact that I will have to go in every 3 mos. for vaginal/cervix/pap in order to TRY to catch it before it gets out of control. My Doctor is going to keep fighting with them but I cannot believe that the Insurance company is the one that gets to make the final decision-someone that has never even examined me or personally seen me for the past 15 years. I don't want to have the surgery for the fun of it-BUT it is better than being DEAD or going through Cancer treatments. Any suggestions???? :hair: :burning:

I would suggest that you make a formal appeal to your insurance company's decision. They've probably never talked with you, or your doctor--just reviewed your medical records. Their denial of payment for the hyst is based on standard criteria, and they're not looking at you as a person. When they hear from you and your doctor about your reasons for this surgery, they probably would reconsider. If both you and your doctor feel that your risk of cancer is very high, and you would ultimately need the surgery anyway, and possibly other cancer treatments, which could cost them more in the long run, hopefully someone with some common sense will approve the scheduled hyst.

Most plans have an MD who ultimately reviews these appeals. Try to find out who that person is, and direct your appeal to that person. Contact their customer service department to find out who that person is, what the emergency appeal process is, etc. When I found out that I needed surgery, I started weeks in advance, checking to see that it had been approved. I called regularly, until I knew it was OK'd. That didn't happen until a few days before surgery.

Techically, the insurance company isn't denying you the surgery--they're denying payment. And most doctors and hospitals won't perform "elective" surgery without some guarantee of payment.

But keep after your insurer, with phone calls, e-mails, letters, faxes. Let them know that you're willing to get your state's insurance commissioner involved, if necessary. It's your health, and you and your doctor need to fight for the benefits for which you're paying. Good Luck!

How utterly frustrating! I can't imagine how frustrated you must be about now!

I hope this gets worked out. I don't have any advice, I'm so sorry!

I am so sorry you are also going through this. I have been fighting with my insurance company since mid-June...actually I was denied five days prior to my surgery.

You wrote:
"I have scheduled my entire work and summer family schedule around this surgery. "

Girlfriend, I know exactly what you mean. I am a school teacher so when I was denied surgery for the 23 of June, it put a damper in a lot of things in my life, let alone the mental anquish it has caused me.

I thought I was rescheduled for the 25 of Aug., because the actual provider stepped in and said it was a GO against the PPO explaining they never deny a claim when it comes from a doctor within the network.

Now, the provider's supervisor tells me today, that the PPO asked that they take it to the provider's medical board. I was like this feels like DEJA VU. :hair:

I have decided to Let Go and Let God take care of this because I am almsot sick to my stomach dealing with it. (Of course, that is what they want, right? for me to give up on the appeal.)
Why do we pay the insurance to be denied??????? :cry:

Another sister e mailed me and said to get your doctor involved and get them talking with the insurance company. I am awaiting for the Doctor and the insurance company's doctor to have a phone consultation on Monday or Tuesday and then this Doctor for the Insurance company will make the decision. But hopefully my Doctor will be able to convince him that this is necessary and that I should not wait and no other procedures are going to make this better it will just prolong the inevitable. Thanks everyone for your support and for hearing me out. I really appreciate it.