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Insurance wont let me go out of network!! Insurance wont let me go out of network!!

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Unread 04-12-2011, 06:25 PM
Insurance wont let me go out of network!! insurance has denied my precertification to go out of network at in network cost to do davinci. They say its not medically necessary to go out of network when theirs a hospital close by in network that i can go to. So now im having a total abdominal hysterectomy April 25th. Its so frustrating!!
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Unread 04-12-2011, 06:38 PM
Re: Insurance wont let me go out of network!!

I'm so sorry! You'd think they'd understand that a less invasive procedure, generally requiring less time in the hospital, would be MORE cost effective! Sheesh.

Unread 04-12-2011, 06:45 PM
Re: Insurance wont let me go out of network!!

I am so sorry that they aren't willing to let you go out of network. Do you have a human resource department that you could ask for help with this. I was in a network only plan for another surgery and was able to use HR to put some pressure to give me pre-cert there. Sometimes, you can get lucky but not always. Sending lots of hugs that everything goes well.
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Unread 04-12-2011, 06:53 PM
Re: Insurance wont let me go out of network!!

I am so sorry to hear that! I work in the medical field and HATE dealing with most insurance companies! Who are they to tell Dr's what they can and cannot do? I am wondering, the hospital you have to go to and the Dr. you have, is just a traditional laparoscopic hysterectomy an option instead of a total abdominal!?
Unread 04-12-2011, 07:22 PM
Re: Insurance wont let me go out of network!!

What about an LAVH or TVH, or TLH? I'd think those are totally standard most anywhere unless either your Dr cant/wont do it and your choice of Drs is very limited. Although in my case initially it would have been TAH if my cancer were higher stage, due to insurance, so I've heard a similar verdict. But perhaps you can still get a traditional lap surgery, it's worth checking if you haven't already. Sorry it's all so frustrating.
Unread 04-12-2011, 07:25 PM
Re: Insurance wont let me go out of network!!

My insurance company said this as well. There were in-network doctors and hospitals. But none of them had expertise on the Da Vinci and I needed that given my other health issues.

The out-of-network doctor wrote up his notes as to why Da Vinci hysterectomy was preferred for me over the traditional surgery. My primary care physician also provided my medical records and tests and actually talked to the hospital adminstrator for the insurance company.

Further, I appealed to the insurance company, which you can do if you are denied. I took their denial and appealed it, writing up my own story why Da Vinci was a preferred method of surgery for me, especially given pre-existing conditions.

After all that . . . and I followed up with every doctor to make sure they submitted their stuff . . . the insurance company approved the Da Vinci surgery. I had it on the 25th of February.

So, don't give up. Appeal. Write up why this is necessary and get the doctors involved. It took a bit of extra effort of everybody's part and I had to constantly monitor my doctors to make sure things were done, but it was worth it.

Good luck.
Unread 04-12-2011, 07:42 PM
Re: Insurance wont let me go out of network!!

I agree with Sassine. Appeal Appeal Appeal! Have your doctor submit an appeal letter explaining why you MUST have davinci. If you push long enough you can get it done. I have to do this every day to get patients pre authed for other things so don't quit eventually you will get your answer! <3
Unread 04-12-2011, 08:43 PM
Re: Insurance wont let me go out of network!!

Thanks yall for listening. My doctor said he would only do a davinci assisted vaginal hysterectomy or abdominal. I think maybe because I may have tons of scar tissue and adhesions since ive had 2 ectopic pregnancies and 2 laparascopic surgeries. I honestly didnt even think to ask him why laparascopic hysterectomy wasant an option. Ive known for a cpl years that my left tube is in bad shape and needed to come out. I wish i had more time to appeal the insurance company but my surgery is less than 2 weeks away and Ive already made tons of arrangements with my work, my husbands work etc to take the time off. I would hate for it to take longer and push the surgery back. It just makes me sick that they would say its not medically necessary. I wonder if they denied me because of the posibilty that the davinci surgery will cost them more?? Im so frustrated with my insurance company!
Unread 04-13-2011, 01:13 AM
Re: Insurance wont let me go out of network!!

Two weeks is more than enough time to appeal. From denial to their okay, for me it was 4 days. I did lots of phone calls and faxes. My original surgery date was never changed and I doubt yours needs to be changed either. Your doctor said Da Vinci or abdominal so his schedule may be the same regardless.

You have time. If you don't appeal, that decision is on you and not on the insurance company. You may have to seek what you desire since they are not allowing it automatically.

I had two myomectomies and there were a lot of adhesions. My uterus was HUGE. I was also severely anemic and I needed to lose less blood and there were host of other issues that required me to have the Da Vinci.

Good luck with whatever you decide and it is your decision. Appeal if you choose.
Unread 04-14-2011, 07:34 PM
Re: Insurance wont let me go out of network!!

It is totally up to you., A lot of time the insurance company will listen to appeals. I recently had them tell me I had to drive 175 miles one way to see a specialist because of cancer concerns(luckily not cancer) and I appealed decision to where they let me go to someone who was only 125 miles away one way. So it was tough but at least not quite as far. It is up to you because a lot of times it just gets to darn difficulty. Sending hugs.

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