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Insurance approval Insurance approval

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Unread 02-19-2001, 12:07 PM
Insurance approval

I am currently anxiously awaiting approval from my insurance co. for a hysterectomy. So far I've been denied once, had another ultrasound and doc is hopeful they will agree to pay for surgery with a diagnosis of adenomyosis. Insurance co. has already mentioned "less invasive" treatment, namely Lupron. I have told them to take a flying leap as I quite reluctantly took low-dose BC pills for 6 mos. and had almost constant nausea, migraines, and then severe swelling on lower legs. I am just not interested in a hormone roller-coaster. I have all the symptoms: pain for up to 2 weeks prior to period, heavy bleeding, clotting, flooding.......... but other than a few local abnormalities on my ultrasound, no real enlargement. With apologies to all of you who are trying to hold on to your uteruses, I am so ready to part with mine. I've dealt with pain and heavy bleeding for almost 30 years, and am sick to death of living around my period. Last period (first one off of pill), I had cramping and back pain for two solid weeks; started a week and a half BEFORE my period. Tried every nsaid in the book including Vioxx, and had to resort to Darvon for relief, but that came with a migraine and severe nausea. I give up!! Have any of you had any experience like this? My doctor and I are actually praying my bloodwork shows anemia ( I have to stop eating so well). Is it possible for an insurance co. to deny me the surgery if I refuse to take either Lupron or another hormone (I have fear they will want me to take Depot Provera)? I have done tons of research - enough to know that only a small percentage of adenomyosis is ever diagnosed before surgery, but I am not terribly interested in undergoing biopsies or hysteroscopes or laproscopes. Anyone have experience with this situation? My doctor is supportive, she's ready to try to schedule me before my next period if we can get approval.

Sorry this was so long!! And sorry if I sound whiny, but I am 40, probably 10 years off from menopause, and sick to death of living like this. I would take the pill non-stop to get rid of the bleeding, but I just can't tolerate the side effects. My husband is ready to pay for the hysterectomy out of our pocket, but I want my insurance company to do it's job.

Thanks for listening.
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Unread 02-19-2001, 12:27 PM
Insurance approval

Wow, you pose a tough question. I would not do the hormones if you can't tolerate them. I was on continuous bcp's twice in the last 3 years and each time when I finally did have a period, it was the WORST time of my life. Except the last time I stopped the bcp's my period never stopped. That's when I found out I had a large fibroid that was causing the bleeding.

I spoke with my surgery scheduler and she said she submitted my paperwork to my insurance (I'm surprised I haven't heard a no from them, but I haven't heard a yes either). I go March 1st so if they need to deny me, they need to do it pretty darn soon. They'd better not, because I, like you, would be willing to take another loan out to pay for it myself. I think I've gone through enough suffering and pain for any insurance company to tell me what I can and can't have done.

Good luck to you and keep us posted.
Unread 02-19-2001, 01:20 PM

I know all too well what you are dealing with, whether you are dealing with an HMO or PPO, whatever, they have to answer to the state board of insurance. For instance, I am in TX and we have had to call Austin (capital) talk to them as calm as you can, they will tell you what it will take to get some resolve from your insurance carrier.

I worked for doctors and have dealt with this from that side and as a patient. That is just the way they do, not to have to pay out... They tried to pull stuff on my mother who had cancer and I got them slammed!!! They handled it.

Be prepared to write letters/e-mail to them also....that way you have it hardcopy.

My adeno wasn't found till surgery, nor was my acute appendix...the insurance company wasn't going to pay for my appie but they now have to pay. My hyster was questionable until the path reports came back.

Stay on the phone, write, don't let up. I am so sorry you have this to deal with, but the best thing is to not give up. It takes alot of energy, but it is worth fighting for...if I can help in anyway just e-mail me.

Good luck,
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Unread 02-19-2001, 01:46 PM
Insurance approval

Hi Kelly,
Thanks for your reply. I hope you get your approval!! My doctor first had to lie to the Insurance co. and tell them a false surgery date as the insurance co. won't even review a case until approx. 10 days before the surgery. Technically, my doc is scheduling into late April, and she doesn't like to schedule surgeries without approval(according to the nurse they've had to scramble on the day before surgery sometimes to get an approval). She's told me, and we'll see if it's true, that she will try to work me in before my next period if we can get an OK. My insurance denied the first request and wanted me to have my second ultrasound in 9 months, a uterine biopsy, and they wanted me to go on Lupron. I cried half the night when I read about the side effects of Lupron. No way. I am so frustruated and depressed from waiting and fearful of my second no-pill period. It is my understanding that it is very difficult to diagnose adenomyosis in some patients, that most are discovered after hysterectomy during the pathology report. In my appeal to my insurance company, I asked them at what point my quality of life was more important than them having a specific diagnosis. It's not like I am looking forward to having surgery. I HATE hospitals! I would have been more than happy to take non-stop BC if I could have tolerated it, but I can't, and the difference in my cycles wasn't great enough to go through the side effects. If it sounds like I have an HMO, I don't. Apparently, I have an insurance company that doesn't want to spend a dime they don't have to. I even had to call them after-hours and raise all kinds of H____ to get my prescription for Vioxx filled because they don't cover that. They covered 5 pills, but were more than happy to fill a whole bottle of cheap Darvon the next day. Go figure. They could care less if I get hooked on narcotic pain killers as long as it's cheap.

I am ready to go to another doctor and have them schedule me for a full work-up including another ultrasound, biopsy, pelvic, bloodwork, whatever they can think of to hopefully add more ammunition to my case. It also pleases me a lot to know that my insurance company is obligated to pay for a second opinion and all the same tests over again. Maybe if they figure out how much I could cost them in the long run, they will approve. As soon as I am post-surgery and past any complications, however, we are dropping this insurance company and finding a new one (we own our own business and therefore pay big bucks every month in premiums). It is just so depressing to have to fight this. I was told 5 years ago by another doctor that he was fairly sure I had adenomyosis and should consider having a hysterectomy as it was the only real way to eleviate the pain and bleeding. I said no at the time as I had just buried my first husband and was not physically or mentally strong enough to go through with it. Now I that I am finally more than ready, I have to fight to get it! I am instituting my "squeaky wheel" strategy, however, and hopefully they will get sick of hearing from me and approve!
Unread 02-19-2001, 02:30 PM
Insurance company stories are disturbing

It is really disturbing to me to hear so many stories about insurance companies. (I sued one myself, so I know how hard they fight. It doesn't matter if it costs more, they stand on principle and don't want to set a precedent for other patients.) Surely something has to change one day so the insurance companies aren't running the health care system in the United States.

As for diagnosing adenomyosis, mine was diagnosed by MRI. That's an expensive procedure you could ask for!

Hope things get sorted out and you get to do what both you and your doctor know is right for you.
Unread 02-19-2001, 02:44 PM

I go to the doctor Thursday to schedule a "firm" surgery date. The pain is getting worse (even though the bleeding has FINALLY stopped.) I am hoping my insurance company will come through with no problems. Fortunately, all the doctors visits in the past 2-3 years should be a huge point in my favour (all things considered.) I'm sorry for all the problems you are having with yours, hopefully they will stop soon. Take care and I pray all goes well in "Insurance He**" for you.

Unread 02-19-2001, 04:34 PM
Insurance approval

Thanks so much for all your support, ladies!! Nice to hear from some who have 'been there, done that,' though I wish none of us had to do it! I like the idea about an MRI.... after literally HOURS of research, I've run across it too, and am SO happy to hear it is expensive! Right now I am at the point that they either pay for it, or I will be sure to cost them more than my monthly premiums. Fighting is the only thing that keeps me from crying, and I've done plenty of that already. My poor hubby and boys......... they lost me to the couch two weekends already this month. I just want to be on the road to recovery by the time we launch our boat on the lake this spring!!!
Unread 02-19-2001, 08:54 PM
Insurance approval

KHill, hang in there! I know this can be frustrating but everyone does seem to have to go through the insurance system. If you do not tolerate BCP then you will not do well with lupron at all and the insurance company cannot ask you to do that. Your doctor should have documented that. They CAN however request a laproscopy to diagnose. Its cheaper than hyst (outpatient) and if nothing is found they can deny surgery. The upside is that most of the time things are found through laproscopy and biopsies can be done at the same time. Its a pretty much painless surgery and if it will help get the hyst covered then by all means I would say do it. The MRI sounds like a better bet to begin with and if all else fails and they still wont pay go the laproscopy route. That should surely come up with something.
It is sad to say but ins companies require so many steps be followed before they will pay for hyst even if it costs them more than the original surgery, but like one of the other ladies said, start popping out some letters to the ins company and state ins dept. If you have an attorney for your business, it might not hurt to have him send a letter on his letterhead. Attorneys make ins companies very nervous. Best of luck to you.
Unread 02-20-2001, 04:49 AM
Insurance approval

Well it looks like I am not the only one dealing with this either...

I was sleepless for a week waiting to get the call from the Dr.s office. They said that they would call ONLY if they DIDN'T get an approval. I still haven't heard from them (a month later) so I assumed that everything was OK?

Now I am wondering..... I guess that I should call and "confirm". My surgery is in a week and I have already given a unit of blood (and another tomorrow). But now that you mention Dr.s scrambling for an approval THE DAY OF SURGERY.... That's scary!

I have been weary of the approval from the start. Mostly because of my age 25. My Dr. said not to worry being that I had already had a tubal (4 years ago) and with my history he didn't expect any problems. However, WORRY is my middle name!

I hate to bother the Dr.s office but, I guess that I that I don't have any surprises!

Unread 02-20-2001, 04:55 AM

I don't think adenomyosis can be diagnosed by laparoscopy. Nor very many times by uterine biopsy. It has to be a deep biopsy and even then, you're only biopsying (is that a word?) one (or two or three) areas and could miss the adenomyosis. Lap is an invasive procedure. MRI is not.
MRI is probably cheaper than a lap anyway.

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