ooph & hyster. DENIED by insurance!!

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wackygal
Veteran Member


Date Joined Jul 2003
Total Posts : 857
   Posted 11/17/2004 3:28 PM (GMT -7)   
AHHH!  got a letter saying the ooph and hysterectomy were denied by insurance (I WELLPATH!!) because they were not "medically necessary" (what the heck???)  so i called and i have to submit a letter of appeal along with any supporting information, etc. etc.  and GET THIS, the ONE physician who reviewed my case who denied it was an ENT (ear, nose & throat) Dr. !! !()*!(**&&%$  
 
I politely asked, will there by ANYONE who is an ONCOLOGIST on the appeal review board (3 physicians)...oh no, not at this stage of the appeal process, Mrs. schoonmaker, there are only 3 board certified physicians, but dont have to be in the specialty of ob/gyn or oncology.
 
i am SO MAD!
 
SO, ladies i need your help, if anyone has links to articles on how removal of ovaries decreases risk of ov ca after br ca, please post them here... also any articles on the characteristics of brca1 cancers.
 
THANKS!
frustrated,
stefanie
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"It's been worth everything I've been through,
 To do what I do"

                       To Do What I Do   -Alan Jackson, 2004


gma
Veteran Member


Date Joined Jul 2003
Total Posts : 2921
   Posted 11/17/2004 3:53 PM (GMT -7)   
Oh dear. How about checking out Sue's FORCE site? I bet there is some information there. I tried to find the address for you quickly but am having problems doing so. sueanddan@att.net is email addy. She will have info to help you I am sure. She is veggievet here and was sfdvm at the village. Insurance is a real problem, but it can be beaten. Hugs MK


Tavish
Veteran Member


Date Joined Jul 2003
Total Posts : 2272
   Posted 11/17/2004 8:01 PM (GMT -7)   
Sorry, Stef...what a pain to deal with! You may also ask your doctors for information/ research that they used to make their decision. Maybe they have additional resources. MK is right, FORCE should have some good information...

Good luck~
Lori


coopfesta
Veteran Member


Date Joined Sep 2003
Total Posts : 1373
   Posted 11/17/2004 9:00 PM (GMT -7)   
Stef:
 
Don't freak.  This is par for the course.  It's just like SS Disability.  They deny everything at first.  This weeds out the ones that won't appeal, then they've saved a buck or two.  You will appeal, and your docs should handle all the researched-based arguments with you.  I predict you won't need to find articles yourself, but Erin left a great abstract on one of my recent posts, take a look at it.  Don't take this on yourself if you can get the doctors to fight it for you.  Trust me, don't freak yet.  The first denial is just that, the first.  I predict it won't be over until an ob-gyn has looked it over.  I remember thinking I had to carry all of those denials, I lost sleep and rehearsed angry statements, the works.  It turned out they were just processes that the companies went through, in many cases, form letters!!!  You need to go through the hoops, but the docs will prevail.  They MUST!!!!!
 
Try to relax.  It will be okay.  I think you'll get it covered.  The oopherectomy, more likely than the hysterectomy.  the hysterectomy is a harder sell, I'm told, unless you're "lucky" like me and have a condition that can help the sale.  Also, try hystersisters.com  They have information there, too.
 
Take care, and breathe
"Our greatest glory is not in never falling, but in rising every time we fall." -Confucius

Ellen


Ynkefan31
Veteran Member


Date Joined Jul 2003
Total Posts : 586
   Posted 11/18/2004 7:03 AM (GMT -7)   
Stef, please email me. I have some links you may find useful, but I do not know how to put them into my post. Sorry you have to deal with this.
nickjoe@yahoo.com

-§»§«:*´`³¤³´`* Vicky «:*´`³¤³´`*§«§-


gma
Veteran Member


Date Joined Jul 2003
Total Posts : 2921
   Posted 11/18/2004 12:39 PM (GMT -7)   
Steph, please note that new member Kimmy2 is from Raleigh, also. Hope you can get in touch with each other and help out in person as well as here. Hugs, MK


Frayda
Regular Member


Date Joined Aug 2003
Total Posts : 248
   Posted 11/19/2004 4:56 PM (GMT -7)   

Steph, were you having any symptoms (cysts, bleeding, thickening of the endometrium etc)? That would satisfy medical necessity along with bc diagnosis.  You can check MSKCC.org and look up my doc, Noah Kauff. On his bio page are links to artlicles he had published regarding brca 1&2 and oopherectomies. Hope this helps! The appeal process can be very frustrating; they hope you will give up, but you can prevail! Good luck!

Frayda


wackygal
Veteran Member


Date Joined Jul 2003
Total Posts : 857
   Posted 11/21/2004 6:29 PM (GMT -7)   
frayda-
thanks so much for the info, i will look it up... i was not having any symptoms to justify a hysterectomy, so if they want to deny that i really don't mind, it's the OVARIES i want out, i have been having non-descript nausea, lower back pain, irregular periods, really bad pain on the left side (my cancer side) during ovulation time, and after all my reading it seems my cancer does have characteristics for brca1 (although i have not been tested) which would increase ones risk of ov ca dramatically, and i just want the darn things out. !!
thanks for the ammo, i will spend some time reading....
hugs, and wish me luck!
stef
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"It's been worth everything I've been through,
 To do what I do"

                       To Do What I Do   -Alan Jackson, 2004


Tavish
Veteran Member


Date Joined Jul 2003
Total Posts : 2272
   Posted 11/22/2004 4:31 AM (GMT -7)   
Stef-
I can't remember, have you considered the genetic testing? If you have not been tested, you might consider that to help plead your case. If you tested positive, I think that would seal the deal for insurance company. Before you agree to any testing, you would meet with a counselor and learn all of the pros and cons, especially how the laws protect you and your family on this issue.

Hang in there!
Lori


wackygal
Veteran Member


Date Joined Jul 2003
Total Posts : 857
   Posted 11/23/2004 3:20 PM (GMT -7)   
Lori-
thanks for the suggestion, and am TRULY not a paranoid person, but somehow i think having this genetic testing done will somehow impact the availabilty of insurance (or medical care) for my daughter in the future. i think that there is a real risk to have that information in a report somewhere that insurance companies can get ahold of... it's the 'holy grail' for them in terms of assessing risk for future diseases, and i don't want that used against my daughter, or any other female relatives (sister, neices, etc.). I think the ethics and ramifications of using that information improperly, outweigh the benefits of me knowing if i am brca1 positive... so thats why in my letter i was careful to say that mine had 'characteristics consistent with brca1'.

make any sense? ;-)
we don't agree on much, do we?? (just kdding!!)
BIG HUG
stef
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"It's been worth everything I've been through,
 To do what I do"

                       To Do What I Do   -Alan Jackson, 2004


Frayda
Regular Member


Date Joined Aug 2003
Total Posts : 248
   Posted 11/23/2004 5:26 PM (GMT -7)   
Steph, just FYI, my genetic testing is not part of my medical record anywhere. The testing is done anonomously (with an ID#) and my doctors do not mention it in their records. They are very careful to protect your privacy and now with the HIPAA laws, it should be impossible for anyone unauthorized to get that information. Hugs, Frayda

Tavish
Veteran Member


Date Joined Jul 2003
Total Posts : 2272
   Posted 11/23/2004 8:21 PM (GMT -7)   
Stef-
I totally understand your fear....when I did the testing, I met with the genetic counselor first. She answered all my questions related to the same issues. Rememeber, the counseling is just information and discussion, no test. The counselor could provide you the information that might change your mind and decide to do testing, or it might firm up your decision to not do it.

Frayda is right, with HIPAA out there now, it is hard to even get your own records! I paid out of pocket for my tests so that the results would not get to insurance at all...and when I tested negative, I submitted the claims and got it covered. But that could be another option...pay out of pocket to keep it private.

My genetic counseling was done at U of M, through the Cancer Center, but the genetic folks keep a totally separate record. Even my oncologist could not get to see my records, although it was in the same facility.

And even if, big IF, you tested positive, there is no guarantee your kids would inherit the gene. So your test results should have no impact on them. I would encourage you to meet with a counselor in the genetic risk area, and let her/him answer your questions. The worst that could happen is nothing...you can decide not to do the testing after meeting with the counselor. I waited 6 months to get tested after I did the counseling...

And it is OK if we disagree! I still like ya!
L&H,
Lori


veggievet
Regular Member


Date Joined Jul 2003
Total Posts : 58
   Posted 11/28/2004 8:27 AM (GMT -7)   
Dear Stef,
Please e-mail me (sueanddan@att.net) and also visit FORCE (http://www.facingourrisk.org).  Many of the women there have had PO to lower their risk for ovarian cancer.  I have articles and there are also articles posted in our reading room under "surgical risk reduction" at:  http://www.facingourrisk.org/readingroom/readingroom.php#surgery.  If you are BRCA positive or if you have a family history of ovarian cancer you should be able to appeal.
 
Warm regards,
Sue
**********************************************
FORCE: Facing Our Risk of Cancer Empowered
for women at risk for hereditary breast and ovarian cancer
"Joining FORCEs against cancer"
**********************************************


wackygal
Veteran Member


Date Joined Jul 2003
Total Posts : 857
   Posted 12/1/2004 5:48 AM (GMT -7)   
sue-
thanks i will check that out... i am waiting for the results of this appeal with baited breath!
stef
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"It's been worth everything I've been through,
 To do what I do"

                       To Do What I Do   -Alan Jackson, 2004


wackygal
Veteran Member


Date Joined Jul 2003
Total Posts : 857
   Posted 12/2/2004 4:35 PM (GMT -7)   
just a quick update.... unofficially (via the obgyn nurse) by insurance company has approved the ooph but denied the hysterectomy... FINE! geez, i guess they have to do SOMETHING to justify their existence.......as long as i get the ovaries out (and hernia fixed) I am happy.

i am waiting for a confirmation letter in the mail.
sorry i haven;t been on the board...family still here from the holidays! i am so truly sorry to hear about Mel... she was so friendly when i met her in myrtle beach... that seems like only yesterday....so so sad... may she rest in peace.

hugs to all,
stefanie
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
"It's been worth everything I've been through,
 To do what I do"

                       To Do What I Do   -Alan Jackson, 2004


Chemosabe
Regular Member


Date Joined Dec 2003
Total Posts : 257
   Posted Yesterday 6:45 PM (GMT -7)   

Stephanie,

Don't give up the fight with the insurance company yet.....push them on giving you the hyster paid, too.  If your company is anything like mine, they are rat bast@#$# to deal with but keep sending paper back at them. 

You know, there are so many books out there on how to cope with bc or whatnot but there needs to be one on how to get your way with insurance companies and doctors. (My DH just opened my eyes to something I never even thought of...bargaining with doctors and hospitals. Maybe you all knew this, but it never occured to me to say to them, "Well, I don't care if the bill is $500 all I am only going to pay $150 and no more and you can take me to small claims court to try to recover your costs but I don't think it will look real good before a judge that you're trying to bankrupt a woman with breast cancer..." He went on in that fashion and they said, "OK, we'll take the $150 and write the rest off." I was stunned!)

Don't let them get you down!  And as for "medically necessary" just what do they think, that women wake up one day and decide on a whim to have major surgery?! Maybe they need more WOMEN on your review board.....Harumpf!

Love,

Erin


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