qu: insurance denial and appeal

[wasatchm]

hi,

just submitted claim for insurance coverage with my HMO and was denied (as expected).  I went through a plastic surgeon on my HMO to see if could get coverage.  he told me an appeal can often times get coverage for this surgery.  my questions are: 1) can I go ahead and pay to have the surgery while I am appealing and get re-imbursed by my HMO for the surgery if I win the appeal.   and if I do win the appeal... question 2) can I get fully re-imbursed for the surgery if I have it done by a surgeon OUTSIDE OF MY HMO PLAN?   if not, do they do partial re-imbursements if I have the surgery done by a surgeon outside my hmo plan?    thanks

[nothingworse]

Wait to get the approval first from the insurance company from the appeal. 1-2 Appeals usually win in a non medical case. If you get it done now and wait for a reimubursement you have a 95% chance of getting nothing back and if you are damn lucky you will get only a small portion of it back and never see it all. And chances would be so slim in getting a reimbursement it would be like 1 in a 100,000 ask me and my family. Same insurance and we have done this a few times and never get reimbursed and you won't. They will just say tough luck. I know too many people in which this has happened to they just don't pay you your money back thats how they operate maximum dollar. Outside your plan they will also most likely not give you even a partial reimbursment. They just won't. So wait for them to cover it, it may take 1-3 appeals and 3-6 months in your case. But, it is hard getting insurance to even cover gynecomastia unless it is medical in the first place. There is also a good chance they may never cover it. So you may end up having to pay for it anyways. Good luck though because I am not saying all this is impossible but, its all very hard. Best of luck on destroying your gyne it is just one hell of a burden.

[wasatchm]

so if I have the surgery and pay for it myself, they feel less obligated to pay even if I win the appeal?   that's doesn't make a lot if sense.  that seems to be dishonest to me.  are all HMO's that dishonest.    so is there any legal recourse if I win the appeal and they drag there feet in re-imbursing?  

[nothingworse]

Yes, they feel less obligated to pay. Its over they don't want to give your money back and will just shu you off. HMO's are terrible about this. My parents had a bad experience and so do many other of my family members and friends. Why should they give you your money back when they really don't have to. Legal recourse you could take is suing. Which really wouldn't be worth it for something this small. Sorry to tell ya but, insurance is a real pain in the a**. I am not saying you absolutely won't get any of your money back but, it would be so hard and most unlikely. The money you spend on the surgery is nothing compared to the feelings and hapiness of being gyne free. Why do we pay insurance? The only time they really cover is for something serious or life threatning or a chronic problem. By only covering what is needed most they make maximum profits and line their pockets. I know it sucks but, if it were for cancerous breast tissue then you wouldn't have a problem or for something else medical. So it is really your choice you can wait out the appeals and most likely eventually win or pay for it yourself. Good luck.

[wasatchm]

well,  I did just receive the denial letter in the mail from my HMO.  I was given a phone number for member services to call regarding making an appeal.  I did call the number and they said it could take up to ONE YEAR to review the appeal.  they have to be kidding right?  ....one year.  

as far as suing them (considering I later win the appeal and refuse to pay for the surgery I have already had), I doubt I would do that on my own.  my only hope would be that the amount owed to me (probably $4k) would be enough that an attorney accept the case and only collect a fee if he wins judgement for me.  

my gene is fairly severe (see pic below) otherwise I wouldn't even of bothered dealing with my HMO and trying to get coverage.

well, I guess I should get on with finding the best surgeon.  so if the breast tissue is removed and found to be cancerous will the insurance company then have to pay for the surgery?   I'm assuming they would.


http://www.geocities.com/bray19702004/frontviewpic4

thanks BA

[nothingworse]

If the tissue was found to be cancerous and they didn't pay you back or never covered your surgery. You would then have a sueable case on your hands. You definetely have a severe case and I can definetely see why HMO should cover it. If it was found to be cancerous it would be rare though and they didn't pay you back and you sued you would most likely win a huge settlement. Although chances are its not it is just overgrown breast tissue. HMO is bad with covering non-medical cases unless they are like 5 times the size of a normal case. I think you have enough tissue and a big enough problem to prove your case with pictures sent in by a surgeon. There is an obvious problem and insurance should take care of your case since it is severe. If this was 10 years ago not only would you get your surgery right away but, you wouldn't have to go through any trouble either. I have the same insurance as you and right now am having a problem with them paying for my medical gynecomastia problem. Heres what you should do don't sue them yet because there is another thing you can do. Call the directors board or get a hold of a head director and discuss your problem. Also depending on what company you work for and their insurance they hold you can go and have your company push your case for you and the companies will rattle up enough trouble for your insurance company. Depends though. They can and would get you the surgery if it is a problem in your case it is. The insurance company doesn't want to lose a companies business or millions of dollars they can't afford to lost that. One person maybe but, not a company. And if you are younger and trying to get your parents have them do this. We are having similar problems with delays and this condition is literally killing me physically. We will do whatever it takes. I advise you to do what it takes you pay insurance you have a problem so push the issue. The more you push the faster and better things will turn out. I am waiting 1 more week for my claim to be approved or denied and everything has come back negative lately and am expecting a denial can't figure that one out because mine is a rare case that is definetely life hindering. Not deadly but, does get in the way and is a problem. If I have to fight I will arson up the largest fight I possibly can I am tired of HMO's crap they are the expensivest and yet becoming the worst of insurances lately. I remember 5-10 years ago when an insurance company would automatically pay for gland removal surgery but, you would have to pay for lipo and anything else extra. I have all gland, thats painful and all I am looking for is my glands to be removed so I can live my life normally and be back to my old self and not have pain anymore. It just gets old after years and years and guess what when the insurance company pays for your surgery guess what they are paying the surgeon 50-60% of what the surgery would have costed you. So basically it is a life improving cheap procedure. Why do they have to be such little bi*tches about it. Everything in this world is getting worse and worse and I have never seen insurance so bad as it has been in the last 5 years it is terrible. Basically to say for the U.S. at least ever since bush got in everything is signicantly worse. Gas up, jobs down, good jobs at least, dirty business, bs, deficits, too much concentration on foreign issues, stupid fu*k Bush. I literally hate his guts. Sorry to say a man like that is just plain retarded. Honestly to tell you the truth if you live in the U.S. I have got to tell you if Bush wouldn't have gotten in and Kerry would have gotten in instead I think right now you or me and everyone else wouldn't have problems like these right now. Medical is so messed up because of him and the way he thinks this country should be. As the economy gets crazier and worst so will insurance and soon you won't know what you are paying it for anymore. My parents are literally psycho about the gas prices and so am I. Damn oil man, go to hel. Sorry for the long post but, like you I don't get it anymore and am just sick of it. I am going into skilled trades and want to be back into workable shape and not feel like crap everyday of the week feeling like I don't want to wake up everday. The pain just gets sickening. I don't know if things keep going the way they are the depression may come back. Some people may not see it but, you have to be blind to see how everything is really getting worse each day. Good luck to you with getting your money back or coverage with insurance. Do what you can push call them bug the crap out of them, keep going and going and you will win and be gyne free. This gyne is just too much.

[wasatchm]

thanks for the response.  so when you say send and appeal to the "director", director of what (customer relations, utilization management).  customer relations  is the department they told me to address my appeal to.  my denial letter came from the utilization managemtn department.   I'm not gonna drag this out much further.  I will keep appealing but will go ahead and have the surgery.  I just lost 15 lbs.  as soon as I lose another 15 lbs (probably 3 weeks) I will schedule surgery for the coming month.  I probably will not have a PS on my HMO do the surgery if I have to pay the cost up front myself.    by the way, I am self-employed.  unfortunately, I have no one to push my case.  before I quit my last job I was with blue cross blue shield (which I think would of covered this).  about the best I can do if I never win an appeal is trash them (and post my gyne pics) on the biggest customer complaint web site I can find.   I did that with Geico last year.  it got quite a few reads and I am sure they lost some customers.  
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this is what the DENIAL LETTER says: after a thorough review by the utilization management department the coverage for this procedure has been denied.  it has been determined that the member does not meet the policy criteria for mastectomy for gynecomastia.  it is therefore considered to be cosmetic.
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however, I've read every page of the policy and gynecomstia is not even mentioned.  mastectomy is mentioned but only in reference to women and breast cancer.    this is what the actual policy (member handbook) says about what is calls cosmetic/reconstructive/corrective procedures:  any care, treatment, or procedure performed primarily for cosmetic purposed is not covered.  any care, treatment, or procedure is considered cosmetic when it is primarily intended to improve appearance or correct a deformity, whether congenital or acquired, WITHOUT  RESTORIING PHYSICAL BODY FUNCTION.  reconstruction or corrective procedures done primarily for the purpose of restoring "normal" body form or appearance are not covered. (this includes reconstructive or corrective procedures to restore or correct non-function-impairing congenital anomalies;it does not apply when reconstructive or corrective procedures are to improve or correct an impairment or loss of bodily function.)  psychological factors such as poor self image, etc are not  relevant even if a doctor may indicate that such factors constitute a medical necessity).
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sounds like they've pretty much limited it so they hardly cover anything (unless your a woman with breast cancer).  I'm filling out the appeal form right now.  I don't know that I can contest anything based on what's in the member handbook.  guess I will just describe the negative psychological effects of severe gyne and  how that affects the health and personal well being of the individual.  
if you have any more advice, please let me know.  

thanks

BA  

[nothingworse]

I would go with what you just said on your appeal and say it does mess you up psychologically. It does, and gyne can totally destroy self image and be very devistating. Also, tell them it is hindering your life, or causing you to not live a normal and happy life. I would call the utilzation management department. As they are heading the claims and basically the top officials that say what they want and don't want to be covered. Just state your case with them try and get a hold of someone who can change the answer. Ask them what you pay insurance for and how this has greatly affected your life. Those dang insurance companies need to learn a lesson or two. What if one of those board members had gyne and was looking for insurance to cover it and they denied them. What would they think? The shoe being on the other foot is what will someday change the decisions about gyne. Also, I have one important question for you regarding my case. Well since I have pretty much the same insurance with pretty much the same guidelines here we go. My case of gyne is purely glandular. It causes me great physical pain and uncomftorablness? It hinders my lifestyle and this surgery is soley being covered on medical reason. Do you think they will still deny my claim or do you think they will approve my claim? Just would like to know since you have freshly dealt with them. Not saying you have the same case though. Mine is really 99% soley for medical benefit. I just would like to know to plan things out and construct more ideas on what to do just incase.  Your input would be greatly appreciated. I am glad you found help in my statements. I am just tired of HMO's crap. My parents go through loops of bs with them now and within 2 years I will be under HMO when I get my skilled trade job in HVAC. Sorry to hear all the crap you have been going through. What you said about losing 15 more pounds then paying for the surgery is a great idea. Thats the best thing you can do to see the best results. Well looking forward to your input on the coverage part I am just a little concerned right now and any info would help. I wish you the best of luck with your dealings with HMO and hopefully soon you will be gyne free. Best regards

[wasatchm]

my insurer is a local HMO (covers only the state I live in).  they are non-profit but that may change.  the state is thinking of making them non-profit and force them to compete with other insurers.  we have the same issue in my state regarding banks and credit unions (credit unions are currently still legally non-profit).  this NON-PROFIT classification is a joke.  it's just a way for the HMO to make more money.     I found that out when I had a CT scan in january.  I went into the hospital and checked in and asked the billing clerk how much the scan would cost (she said depending on the number of scans and time $550-$1100).  as soon as I was hooked up to the machine to begin the scan I asked the tech how long this would take.  he said my scan would be a very quick one (I think it ended up being about 25 minutes).  I thought cool, I will probably only have to pay in the low end of the price range ($550 or a little more).  I got the bill and it was $1087 (actually $1120 if you count the dye used to inject in my bloodstream).  my HMO did cover part of it.  after getting the bill it was clear something didn't jive (one of the quickest scans they give and I pay just about the highest they charge).   I think I will eventually switch over to a nationwide healthcare provider.  I think I will get treated better than a local HMO.  

as far as your case.  I don't know that I can say a lot.  I do believe probably most all healthcare providers will automatically deny any gyne surgery initially and make you appeal.   I think if one or two large healthcare providers do an automatic deny, then all the rest do also.  they all want to be on a level playing field.  If one doesn't deny the claim, then they may not be able to offer competitive monthly rates for insurance.   that's how the car insurance industry works.    I think the HMO already knows if you will eventually win your case or not.  the question is how many appeals to have to go through to get the procedure covered.   my HMO has 3 levels of appeals.   I think I will have probably already have the surgery before I hit the second appeal.  somehow HMO's need to be pinned  down on what they  do and don't cover.  they just need to put it in the policy (except be very specific).  I really don't expect most cases of gyne to be covered (guess it's just to common).  if one has a severe rare case  they shouldn't put you through all this garbage.  they shouldn't have these boards that review cases and play god and make a judgement call.  there is NO REASON for it.  just put it all in the DAM policy book.  be very specific if you have to.  it's the only way to be fair.  as for as gyne goes, I don't know how they think that they have a specialist that knows best whether it is medically necessary to remove.  you'll have to tell me how it goes.   my fear is if I have the surgery (pay for it myself) and then later win the appeal I still don't get re-imbursed.  I would think that if you win the appeal they would then have to pay  for the surgery (regardless of whether you already had it or not).  guess I should just be glad I can afford the surgery.  I just get much more worried about a botched surgery when I am paying out of my own pocket.

BA  

[Paa_Paw]

Sadly, Your analysis of the language in your medical policy seems to be correct.

HMO coverage is cheaper than Medical Insurance precisely because there are many things which are specifically excluded from coverage.  Anyone who buys into A HMO should understand that.

Unfortunately, If you were to drop the HMO and replace it with conventional Insurance now;  Your Gynecomastia would be a Pre-existing condition and not be covered for a prescribed waiting period which might be several years.

Your choices may be limited to accepting your condition or paying for the surgery out of pocket.

The degree of disparity would tend to push the decison toward surgery.

Trying to sue an HMO is so futile that few attorneys would accept such a case without a good retainer.  Conversely, If the case was actually winable,  you'd have no difficulty finding someone who would take the case for a percentage of the judgement.

[wasatchm]

ya true,  if I do look at the policy.  I would feel kind of stupid appealing.  I mean, what would I appeal it on?  I assumed that all insurance policies are writtten as fairly limiting (is there even insurance companies that say they will cover severe gyne surgery?).  it's just that even people that work for the HMO say you can only get approval for this type of surgery on appeal.  ********************************
however, they denial letter I received has flawed logic.  it basically says I don't meet the criteria to be covered by the HMO for masterctomy for gynecomastia.  since this procedure is not covered by the your policy, it is CONSIDERED TO BE COSMETIC.  it seems like they decide what they will and won't cover (as far as plastic surgery goes) and then say "whatever we don't cover is considered cosmetic".   although I do think I can make a case that mastectomy for severe gyne should be considered "reconstructive surgery".  if the HMO can rubber stamp any procedure as "cosmetic" they never feel obligated to cover it.  according to the american medical association RECONSTRUCTIVE SURGERY IS:
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Surgery performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function but may also be done to approximate a normal appearance.
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whereas COSMETIC SURGERY IS DEFINED AS:

surgery performed to reshape normal structures of the body in order to improve the patient's appearance and self-esteem.
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shouldn't any insurer accept the definition of cosmetic and reconstructive surgery by the "AMERICAN MEDICAL ASSOCIATION"?  

well, I'll have to include it in my appeal letter.  I certainly don't want to try and are with them in an appeal letter.  though any good facts I can put forward the better.   I hope this doesn't drag out.  If they won't cover it (regardless of the devasting effects it can have on an individual) fine, just tell me.   I really don't believe in appeals and that whole process.  well, one appeal and a response from the HMO within 30 days would be alright.  my HMO has 3 levels of appeals that can take up to a year.  

well wish me luck,  hopefully I will have my appeal mailed in with the next 24 hrs.