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What is the criteria for having a hysterectomy?? What is the criteria for having a hysterectomy??

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Unread 03-28-2002, 02:04 PM
What is the criteria for having a hysterectomy??

HI Ladies!
I can not find any info regarding what exactly the criteria for this surgery is. I was denied surgery because they said I don't met the the criteria for coverage for this procedure. What the heck to they want? The insurance company will not tell me, the medical reviewer only tells me what I wrote above and my Dr hasn't said. He's suppose to be calling the med reviewer himself.

I have had previous surgery for endo, a lap/hysterocspy, and endometrial biopsy, a uterine biopsy, heavy bleeding for several years, horrid pain w/ periods my whole life, been on bcp continual for a year to try to surpress periods and that doesn't work at all.
Of course my lifestyle is totally interupted by all this pain and bleeding, the intimacy with my husband has been gone for a long time, I can't go anywhere or do anything for several weeks a month because of this. What more do they need??????

I have tried to find info on the web regarding what the ACOG critiria is and basically all I can find is that they want you to try everything else before doing a hyster. Isn't what I 've already done enough? Can they make me do more?

Please help if you have any answers! Thanks so much! KimAZ
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Unread 03-28-2002, 03:46 PM
What is the criteria for having a hysterectomy??

You poor thing! Your story of suffering is my story, but I found a wonderful doctor who knew how to word things in his report to the insurance company, I guess. The nurse said my paperwork was returned within a week with approval. They said that was extremely quick. Ask your doctor all of these questions. Why does he think you were rejected? Should you resubmit? Do not give up!!!! Speaking to supervisors can sometimes get action.
Unread 03-28-2002, 03:57 PM
What is the criteria for having a hysterectomy??

Hi, Kim - I'm so sorry you're going through insurance hell on top of everything else.

I don't really have any answers. if you haven't already tried it, I would call the insurance company, ask for the supervisor of the person answering the phone, and politely keep asking for their supervisor and their supervisor to try and get someone with the authority to give you answers. Also, there is probably an insurance commissioner in Arizona - maybe you can contact their office.

I wish all of us were making the decision about it, cause you'd be in there getting the help you need.
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Unread 03-28-2002, 04:11 PM
What is the criteria for having a hysterectomy??


I had the same thing happen to me. I have a friend who is an OB/GYN and she said sometimes they just have to deny so many. She told me to fax them with a written letter explaining all the problems and procedures that have been done and tell them it is also affecting your quality of life and your doctor deems this neccessary and you will also write a letter to your state insurance commissioner. I did exactly that and also had my doctor fax them along with a written note from him. I had approval that same day! Amazing isn't it?

Good luck!

Unread 03-28-2002, 04:27 PM
What is the criteria for having a hysterectomy??

Hi Kim!

I am so sorry. It really does seem to be the doctors who "speak the language" to insurance. I wish I could help. My story is so different from most. I went for my yearly pap in Nov. I mentioned some problems with incontinence. The gyn. wanted to refer me to a urologist, but made no mention of a hysterectomy. Since I only saw her once a year, I called my internist, whom I see at least once a month. He referred me to a urologist that he prefers. When the uro. examined me in Dec., she could not believe that the gyn. had not recommended a hysterectomy. The uro. said that so much had prolapsed that the only way to do all the repairs was to do the hys. She referred me to a new gyn. By January all doctors were in agreement. It was really all very fast. When I went for the yearly pap, I never dreamed I would soon be having a hys. I knew I was having a lot of problems, but did not realize that they were related to this.

It has to be how the doctors word their reports to the insurance companies.

Unread 03-28-2002, 05:46 PM
What is the criteria for having a hysterectomy??

Hi Kim,

I'm so sorry that you are having problems with your insurance company . I don't know what the criteria is, but will try to find out.

Hopefully, after your doctor talks to the insurance company any confusion will be cleared up right away.

Please let us know what happens.


Unread 03-28-2002, 05:54 PM
What is the criteria for having a hysterectomy??

I am so sorry you are going through this. I know what you are going thru, as it happened to me last week. My surgery was scheduled for Monday 3/25, and on Thursday 3/21 I rec'd a phone call from my Drs office saying that my insurance denied. I appealed, the medical examiner upheld... and in my case it was because my Dr wasn't one of "their" drs... Persistance does pay off however, as I am now approved (although had to go to a new Dr) and my surgery is scheduled for 4/2... Don't give up! You'll work thru it.... I know its hard. You want to just fall in bed and stay there! Hang in there! Will say a prayer for you!
Unread 03-29-2002, 08:25 PM
What is the criteria for having a hysterectomy??

Hi Kim,

From what I understand from my medical billing days, (OB/Gyn was one of the practices that I worked for) most times there are not any specific "across the board" guidelines that all insurance companies follow, at least not that I'm aware of.

They each have their own criteria that they follow. Here in Colorado, some insurance companies took their lead from the Blue Cross, Blue Shield guidelines which in turn take their lead to some extent from HCFA guidelines.

Most insurance companies have specific requirements based on procedure and diagnosis. If the diagnosis is not considered "life threatening" they may have guidelines set to try any and/or all "non invasive" types of procedures prior to giving authorization for a non reversable invasive surgery.

A couple of things you may want to check into are: Talk to your human resources person and see if they can help in contacting your companies insurance representative to find out if there are any specifics outlined in your particular insurance policy. Also, find out exactly what diagnosis your physician supplied to the insurance company for approval reasons and make sure it "IS" the correct one, there are cases where the wrong diagnosis may have inadvertantly been entered resulting in the denial.

This is addition to what the others have already suggested might be a good place to start. Your Dr should be able to assist you and provide any documentation need to prove "medical necessity".

I wish you the best and hope you'll be able to get this resolved. Please keep us posted on how things are going and if we can help in any way, please let us know.


Unread 03-30-2002, 01:57 AM
What is the criteria for having a hysterectomy??


I am so sorry you are having to worry with insurance. I too am going through the motions to get a hyst done. Mine is scheduled for 4/22. This might help you though. I was referred in the middle of February to a ob/gyn due to the fact I have enlarged (continuously, as in 6+ months) tonsils and lymph nodes from my rural dr. We thought I might have another PID infection again and since I had been experiencing so much pain and that, she referred. Key is to be referred in my insurance. Week later, I saw the ob and was scheduled for a vaginal hyst. While there she asked for insurance, and was specific-
Do you have severe, lifestyle changing pain 2 or more times a month?
Activities limited due to pain/periods?

And, cross our fingers, it looks like my insurance is taking care of everything. The next day I got my blood work and vaginal sono, which proved that I had to go see the urologist for urodynamics since she decided that I may have ovarian cancer and we can't do it vaginally! I have seemed to notice that things snowball, at least in my case! I got my insurance in January, and getting a hyst in April!!!! I hope the above helps you. I remember her asking these specific questions and telling me that they were for insurance, because I told her that I WOULD NOT and HAVE NOT let the pain control me. Like the others said, its all how its worded.!!!!! Lots of luck and best wishes - Carey
Unread 03-30-2002, 10:01 AM
What is the criteria for having a hysterectomy??


I am having the same problem as you are, Kim. I just received a letter in the mail yesterday that said the insurance reviewer was requesting a TAH Criteria Sheet and Medical Notes. My problem is that I went in for my annual physical and my dr referred me to a gyn because of back pain and heavy periods. The gyn scheduled hyst for 4/9 based on a 1/2 hour exam that found large fibroids and family history. I haven't done any of the other treatments that might avoid hyst. I called both drs only to find out they were closed for the weekend to see if they could help. I then called insurance company only to find out that I knew more about what was happening then they did. The contact person in the letter was also gone for the weekend. I am planning to call everyone again Monday. If I don't get answers then, my pre-op appointment is Wed. and I can talk to dr. then. Hopefully, everything will be approved by then. DH says we're doing it anyway.

Let's just hope and pray that everything works out the way we want. Good luck to you.


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