insurance not going to pay

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kat1611
Regular Member


Date Joined May 2011
Total Posts : 104
   Posted 8/14/2011 10:29 AM (GMT -6)   
You have got to be kidding me. Our insurance changed, so did the dr.s who were on it . It took me a while to find a new pm dr and the new insurance co actually has a dep. to help find dr.s I went to one place which wound up resulting in me filing a report against the dr. In the end my file shows that. Also my file shows that all my records are with my old pm dr that I continue to pay out of pocket. When I need meds. my new ins pays for them and when I had a consul. with my surgeon that was referred that was on their list it was payed for. When I had my trial for my unit there was a mix up but got straightened out. Now that I have my perm. in, which is way more expensive, the ins. co are telling me I didn't do things right and they aren't paying for it. They have already decided and I have 180 days to respond. I have all my files at my old pm dr, this makes me furious, who will fake pain? Oooh, I'm bored, I know, I'll have back surgery and make my insurance pay for it. Really?

Screaming Eagle
Forum Moderator


Date Joined Sep 2009
Total Posts : 5005
   Posted 8/14/2011 11:16 AM (GMT -6)   
 
      Kat1611, your post is a bit confusing to me. Why are you paying an old PM Dr that is not your Dr anymore? When you changed Insurance company, did you also get a new PCD first, then have him refer you to a new PM?
 
   Sorry...I guess it's the meds, but I find your post hard to follow.
 
  Can you make it a bit clearer for this old man! wink
 
   SE
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kat1611
Regular Member


Date Joined May 2011
Total Posts : 104
   Posted 8/18/2011 5:50 PM (GMT -6)   
Sorry it took me so long to answer. I was upset when I wrote this. I babbled about the change in dr's but that's not the problem. The problem is when I had my trial unit and perm. unit put in I had to be pre-certified. The place where I had it done won't take you if you aren't. I got a letter from my insurance co. telling me that the claim is being denied because what I had done wasn't medically necessary. That I didn't send enough information in to prove after 10 or so years that this unit would help. They said that since it had been years since I tried the cortizone shots that I could have tried them again to see if they would have worked. That I should have tried more physical therapy even though it's in my file that it didn't help. Maybe a set of shots in between each disk. All of these things would have been CHEAPER. I'm surprised they didn't suggest that Kenny just hit me with a broom! The vibrations would be the same.

Angeleyes13
Veteran Member


Date Joined May 2011
Total Posts : 636
   Posted 8/19/2011 9:53 AM (GMT -6)   
Yes, these guys will do anything to avoid paying. I am always leary when I get a phone call looking for information from my insurance company.

about 10 years ago when my back pain started I had a team of doctors saying the a breast reduction would drastically help my back pain. Back then I was 44DD, and had DJD and DDD, but had my family doctor, PM, orthopedic, chiropractor and reconstructive surgeon all say this should help me avoid rapid progression of by back pain. My surgery was denied, as was 2 levels of appeals and a final appeal thru my employer. All reviewed by a nurse case manager, initially till the final review board. None of my drs could believe I was denied.

10 years later I am suffering, who knows if a reduction back then would have prevented most of what has happened. If I think about it, it only makes me angry.

Not sure what recourse you have now kat. What are they saying about the fact that someone precerted the procedures? It was pre-approved based on their guidelines, right? As you said a doctor will not just put them in without checking this first. Just a question that came to my mind, was this precerted by the first insurance company and done under the second company? That would make a difference. That is the only thing that I can think of, but I still am not clear on your time line.

I guess everyone should take this as a lesson to make sure EVERYTHING is documented in black and white in your medical record. Every complaint, fall, injury you sustain due to your pain, events you miss due to uncontrolled pain, work accomodations, medication side effects, things such as meditation, relaxation, yoga, etc........

I wish you luck with your appeals Kat!

Big hugs,
Shell
DX: CRPS, Fibro, CP, DDD, DJD, OSA, Syringomyelia, Arachnoiditis, failed fusion. Fusions C5-6, L5-S1, hardware removal and removal of scar tissue. SCS trial successful awaiting placement.
MEDS:To many to mention, changes every week it seems.

straydog
Forum Moderator


Date Joined Feb 2003
Total Posts : 16304
   Posted 8/19/2011 11:40 AM (GMT -6)   
Kat my experience has been even though we may get a pre-cert there is a clause in the policy that states that is not a guarantee of payment. I always thought if they okd the pre-cert it was approved, I was dead wrong on that.

Back in the early 90's I had the pill camera test done and was pre-certed by the ins company or else the dr would not do the test. We assumed it would be paid for, they said it was not a medically approved procedure and still under investigation. It had at that time just been approved by the FDA.

You need to give your PM dr at the time of the trial a copy of that letter and he needs to step in on your behalf and send them a letter and any documentation he has setting this all out as to what led you to having the SCS put in.

Let us know what happens but above all get a hold of the PM dr you were seeing at that time on this. Take care.
Moderator Chronic Pain Forum

Retired Mom
Veteran Member


Date Joined Feb 2010
Total Posts : 1753
   Posted 8/19/2011 3:24 PM (GMT -6)   
Hi Kat,

Something similar happened to me a while back w/RFA's and, after going back and reviewing the information SEVERAL times and not giving up, the company who files the insurance claims for my PM wrote off the entire procedure. What happened was that it was precerted, but then deemed not medically necessary. Because the Dr does not do procedures without precert on file, they finally just decided to pay it for me. The Dr's office found a new way to file for the next one and it was paid (after only two appeals). It had something to do with the documentation not being submitted in the correct format and/or with the correct codes.
TLIF L5-S1/failed, Pituatary disorder w/HGH deficiency, Fibro, Failed Bladder Surgery & Nissen, GERD, OCPD, GAD, MDD, CFS, TMJ, Migraines, Pre-glaucomic, HBP, Idiopatic Reactive Hypoglycemia w/Diabetic reaction to HGH, Bi-lateral CTS (surgery related trigger finger), Edema, Tarsal Tunnel Syndrome, Peripheral Neuropathy, Plantar Fascitis, Tibular Tendionitis, Adult Onset Flat Feet & much more.....

Jim1969
Veteran Member


Date Joined Jul 2009
Total Posts : 2042
   Posted 8/19/2011 6:15 PM (GMT -6)   
Sounds like these precerts are really saying is that the insurance company will pay for it so long as when they get the bill they do not find it too expensive.
2 confirmed herniated lumbar discs. Spinal Arthritis. Spinal Stenosis, diabetic peripheral nueropathy.
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