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how do you prove that you need this surgery?? how do you prove that you need this surgery??

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Unread 03-25-2002, 03:34 PM
how do you prove that you need this surgery??

HI Ladies!
I am so upset! My insurance company's medical reviewer says there is not enough medical evidence to warrent a hysterectomy on me.

What do they want? I had stage 3/4 endo lasered off and a uterine polyp removed in a lap/hysteroscopy 4 yrs ago, have had horrid pain with AF my entire life, cramps, back aches, etc etc, and have been on bcps for almost a year now, continuesly to try to surpress AF and it doesn't work at all so I bleed for weeks on end at any given time. What am I suppose to do to prove that I NEED this???

The nurse at my OB's office tells me that my u/s came back fine...OMG! How stupid is that? AS IF u/s shows endo, pain and bleeding!!! I had fertility problems for over 3 years and now my family is complete and I can't stand this pain and bleeding controlling my life. Of course when I called the nurse and the insurance co to ask what exactly merits surgery, they can't tell me! UGH!!!! I am at my wits end and literally feel like I'm on the edge of a breakdown.

It's now a waiting game as to what the medical reviewer will do. Did any of you have to prove your problems? Obviously whatever info my OB sent in to get approval for me to have this surgery was NOT enough. Thanks in advance for any help! KimAZ
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Unread 03-25-2002, 03:55 PM
how do you prove that you need this surgery??


I am an LVN and dealing with insurance companies for prior auth's and pre certifications is my forte. I have done it everyday for years. If you email me with your contact information I will email you my phone number. Then we can talk and I will gather all your info and help you if you like. My email is
Unread 03-26-2002, 09:12 AM
how do you prove that you need this surgery??

Oh Kim.....this whole thing just stinks! It just ticks me off that insurance companies have so much control over lives.....what makes them think that they know better than we do.....or even our doctors for that matter. And that nurse that think endo shows up on an u/s ?!?!? OMG! Unbelievable! I've had countless u/s and none of them ever showed that I had endo much less the extent of it! Sorry to vent....I am just sooo angry for you!

Has your obgyn talked directly to the medical reviewer at the insurance company....sometimes that can clear things up? Another thing you can do is document all the treatments you've done for endo, such as laps, lupron, bcps, and attach a personal letter to that describing in your own words your pain and why you think you need the hysterectomy. And keep calling the insurance company and bugging them!!!! I had to do this once to get Lupron approved.....after about a week of calls they got sick of me and approved

((HUG)) I know you've been thru a heck of a lot and I think that you are making the right choice for yourself and your family.....I am praying that your insurance will get a clue and approve this! Hang in there and email me anytime!!
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Unread 03-26-2002, 11:00 AM
Proof of surgery

Kim, You need to speak to your doctor. He is the one that gives diagnosis. Sometimes the more diagnosis on a insurance claim the better. It's a big game, sorry to say, but some one who could be flippin burgers at Burger King is telling you you are not qualified for a hysterectomy and that the surgery is elective. Have your doctor speak directlywith your in. co.. If he is not on your side I suggest you find another doctor!!!!!!*punch* Best of luck Sincerely, Karan
Unread 03-26-2002, 02:11 PM
how do you prove that you need this surgery??

That is my BIGGEST fear when I go see the doctor next Tuesday!! I am not sure what they expect or what they consider "all other options", but my mom does transcription for a hospital and was an office manager in an OB/GYN's office for over 20 years and she said that with my condition (adeno), they usually want a history of b/c pills, Lupron (or other similar), and possible a dnc...I have an HMO and have met 2 of the 3...don't take no for an answer!! I agree, you should definately talk to your doctor and possible get a second opinion...don't give is our bodies, our pain...we should have the choice! Please let us know what happens!
Prayers are with you!

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