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While I'm not new to this site, this is my first post...
As I’ve been reading through posts on the various boards I’ve noticed that for some women their surgeries were considered “elective” by their insurance, or in other instances they had to battle with their insurance companies. I’m kind of stunned to find out that surgery or treatment to alleviate issues may be considered elective. I’ve never had that problem with previous GYN surgeries (including my abdominal myomectomy in 2002), but am particularly concerned about this since one of the reasons for surgery is fibroids.
While I’m going to ask my doctors about whether they think there will be any insurance coverage concerns, I’m wondering what experiences and/or thoughts others may have on this topic. My surgery isn’t scheduled yet since I still have to meet with the GYN ONC next week… still clarifying all the factors necessitating my surgery and what surgeons may need to be involved. Current recommendation from my GYN for me is TAH (maybe SAH) with BSO… not clear yet if there are cancer concerns (will hopefully know more next week), but definitely issues with fibroids, adhesions, ovarian cysts, PCOS, severe pelvic pain, etc. Does it all hinge on what diagnosis the doctor(s) use?
Considering all of your issues, I am sure yours will not be considered elective.
I work with a girl who wanted a hysterectomy. She is post-menopausal and hasn't had a period in several years. She was having some abdominal pain. They did all sorts of tests and could not find anything wrong at all. She insisted that they remove her uterus and ovaries. Initially the doctor refused, but eventually he gave in and did it. I don't know if the insurance company paid for it or not, but in my opinion that would be a situation where it would be considered elective.
Most hysterectomies are elective surgeries. An elective surgery doesn't mean that it isn't medically necessary to have it done but rather that it isn't an emergency situation where it has to be done immediately to preserve life.
It is my understanding that any surgery that is not done to prevent loss of life or limb is considered elective. Having said that, most insurance companies realize that even though it is elective, it is necessary to relieve the problem. And from my experience, if a doctor thinks it is necessary, he knows what to do to get it approved.
My insurance company kept my approval on hold for about week while they questioned the need for it. Part of their issue was that I was diagnosed with endo six months before and they had no record of me trying any of the other options for treatment and I didn't have a negative pregnancy test on file. So I went in to have the pregnancy test done and told the nurse my negative feelings on the meds and the fact that I was 39, had one son who was 19 and three miscarriages after him and I was done. A few days later it was approved.
Thanks for your input ladies! I'm feeling a little silly now for asking the question... probably should have thought it through more. However, when it comes to how insurance deals with stuff sometimes logic doesn't apply...lol
I would think that if a woman is having period issues (heavy bleeding, clotting, horrendous cramping, endo, etc) that an insurance company might consider it elective (and not cover it) if the woman (and her doctor(s)) hadn't attempted other treatments prior to the hyst.
When it comes to insurance claims, you are - and somethimes have to be - your own best advocate. I totally agree that when it comes to insurance companies logic does not apply.
My surgery was pre certified by the insurance company. yet the same insurance company denied my gyn onc's surgical bill. I asked the insurance company to review the claim - they denied it again - so I appealed. After reviewing the "clinical records" - which were simply the doctor's pre-op vist notes, the surgical report and the path report - the insurance company's doctor decided I did, indeed, need a hysterectomy for endometrial cancer. And, yes, my diagnosis before surgery was endometrial cancer!
I ran into a problem with my insurance company for they wanted to make sure I tried everything else possible to avoid surgery - they had me go on birth control, hormones, have D&C/ Laproscope.
Their main problem with the diagnosis of adeno (even thow I had endo as well). Apparently adeno is hard to "prove" existence until after the surgery due to it being in the lining of your uterus. Even though my sonogram showed an enlarged uterus and fibroids they for the most part said "prove" the problems.
I remember one phone call to the insurance co. I invited the idiot, sorry lovely young man on the other end of the phone to join me at my home every month either during the first or third week of the month to have fun along side me. Funny he never showed up/
No question is silly, I have found every question asked on these boards has definitely had merit - quite often for myself, too !!
I wonder also if I would have had a more difficult time getting my TAH approved if I had not had the attempted D&C/ablation in June.
Once my dr. got in there and looked around (I was to have a tubal at the same time) he stopped the surgery because he knew the route we were taking would not work.
Unfortunately the way insurance is set up, he could not proceed and go ahead and do the TAH at that time because at that point it had not been pre-approved.
If insurance companies would allow doctors to make these determinations at the point of realizing the requested procedure was no longer appropriate, I could have had one surgery and saved the insurance company about $14,000, which is what the first procedure ended up costing even without it being finished.
Instead I had to come back a month later for the TAH (no issues getting it approved) and this time the total cost is right around $35,000.
If any of you were paying the bills, how would you do it? Yep, me too !!!!!
My dr. said insurance companies will not budge on this and physicians have been complaining about this for years, to no avail.