United Health Care Insurance - denied coverage

[Doreen1]

As I read your post regarding pre-0p approval, I got confused a bit. I have the date that you joined the forum and the date you posted in response to my thread.. Your signature says surgery Nov 2011.

I wonder if a peer to peer chat would do the job. Sure that Bridwell and Lenke are in the pool so it would be silly for me to call Bernie and tell her (?) as this is 9 months old and United HCare had time to be more detailed on this document? I am making myself wait as I believe that the office does not want to submit a pre-op approval until later and closer to the date of surgery otherwise the insurance would come back for some other ways to deny.

Hi Gardenia,

Correct, I joined this forum in July 2011 and my surgery was Nov 2011. I don't know what the "normal" process is for a surgeon to try and change an insurance company's stance, but Kelly of Dr. Lenke's office and Dr. Lenke, himself, told me they had never experienced this before where the entire surgery was being denied.

How long has it been since you've talked with Bernie? I recommend talking to Bernie and say to the effect, "...a patient of Dr. Lenke's had this same issue in late Nov 2011... Dr. Lenke resolved the issue with a peer-to-peer call with UHC..." Since Lenke and Bridwell are in the same practice, it may be helpful for Bernie to know how Kelly and Dr. Lenke resolved the hiccup.

Keep us posted on the outcome.

Warmly,
Doreen

[gardenia]

I will but since Bernie called me as I returned from a month of testings in St Louis, (immediately the following Monday) because the practice recieved a 25pg document from the insurance company to which she said to give them time to resolve this. Her advise is to not contact the insurance myself as they have not submitted my pre-op approval yet.

I wish I could read the content of that 25 pg document but it would mean nothing to me as their practice is well equipped (I hope) to circumvent whatever roadblock.

Does anyone know how close to the surgery date does a physician request the pre-approval? I know that it does not take very long (less than 2 wks?) Maybe, they are preparing before submission.

I will call her again but feel bad doing it...

gardenia

[jrnyc]

Gardenia
i am so sorry you are going thru all this stress caused
by an insurance company...

would you consider starting a thread asking fellow forum
members to call/write to AARP to tell them what is going
on with United, and that they will reconsider getting United
insurance because of what they are doing about spinal
surgery....?
personally, i need to find a new company in about a year....
and i will, on my own, write to AARP and let them know
i must reconsider my choice based on United's treatment
of spinal surgery patients....

do you have ANY objection to my doing so...?
i will not mention any names...

jess

[gardenia]

I have no objections to you doing it...

Gardenia
i am so sorry you are going thru all this stress caused
by an insurance company...

would you consider starting a thread asking fellow forum
members to call/write to AARP to tell them what is going
on with United, and that they will reconsider getting United
insurance because of what they are doing about spinal
surgery....?
personally, i need to find a new company in about a year....
and i will, on my own, write to AARP and let them know
i must reconsider my choice based on United's treatment
of spinal surgery patients....

do you have ANY objection to my doing so...?
i will not mention any names...

jess

Hi Jess,
I would be totally OK with you doing this yourself but it will be hearsay from hearsay.

The reason that I have not is because we have the insurance thru my husband's work and it is quite a good plan. I am an AARP member but I do not have the same motivation. I hope this could be resolved in a good way between the surgeon's office and our insurance plan. We have plan coordinators that we could use and they would have to review the data that I am not even privy to.

Without knowing or seeing the 25pg document, I would not be complaining correctly because all I know is what Bernie told me. Maybe, there could be mis-interpretations or different plans or companies receive different coverage. At this time, I am in wait and hope that my chances be good. I hope that those backing WashU can fight fairly as this is why they do research and BMP (off labeled) has been used for many in posterior fusions the this institution. At least, it is not the one-man business operated surgeon that would just move to the next patient in line (I sincerely hope and maybe kidding myself).

You never know what would happen from one year to another and the insurances can do or cover as they see fit. I have no real data in my hands.

[jrnyc]

well, since you have no objection....
i am going to bring it up when i write/call United....
i have work related insurance now, but it is much more expensive
since i retired...it also opts to pay almost nothing since i had to take
Medicare when i went on disability....i pay alot for both me and my husband,
but get lousy coverage...so i will be looking to change in a year and a
half or so....and i sure do not want to pick an insurance company that
is able to get away with rejecting an entire surgery based on BMP...
we have all heard of insurance not covering BMP, but they pay for
all the rest...
i hope the surgeon's office is able to work it out for you...

jess...& Sparky

[gardenia]

Please let me know

well, since you have no objection....
i am going to bring it up when i write/call United....
i have work related insurance now, but it is much more expensive
since i retired...it also opts to pay almost nothing since i had to take
Medicare when i went on disability....i pay alot for both me and my husband,
but get lousy coverage...so i will be looking to change in a year and a
half or so....and i sure do not want to pick an insurance company that
is able to get away with rejecting an entire surgery based on BMP...
we have all heard of insurance not covering BMP, but they pay for
all the rest...
i hope the surgeon's office is able to work it out for you...

jess...& Sparky

Dear Jess and Sparky,
My doctor has not submitted pre approval to UHC so I don't want my name coming up or records flagged. However, it would be legitimate for you find out about this situation if you require an operation say next year. You will want to understand what is covered and what's not so that when looking for a specialist you are not wasting your time going to someone who will prefer or work solely with BMP on their toughest cases. I know that they will not use it in adolescent or younger patients.

My husband was regretting that I would not seek advise years ago but years ago was not in my destiny. I could not even consider having my spine touched when I was functioning as well as I could. But, this year the pain started and in my case it has come rapidly not by stages. For years, I could take a Vicoden and be fine. Last night I tried 2 vicodens at dinnertime and was worse as I could not sleep unitl 3am.

I like to hear if they would give you an answer because even if you get a pre-approval they will claim that is not total assurance of payments as if they like when they feel like denying a portion or all, they will. That is just like playing poker or negotiating at a street bazaar but you can't walk away and not buy. They won't give you a price until you are willing or have the benefits on hand.

gardenia

[jrnyc]

i am not sure as yet whether i would require BMP...
i would be having modified minimally invasive procedure,
rods from posterior, and discs from side...
i have not yet scheduled another appt with NYC surgeon
i would use...i am extrememly ambivalent about the whole thing,
even though my lower curve has supposedly gone from 61 to 70
degrees in 2 years, per latest X ray....i do know my DDD is getting
worse, but we thought my curves were "stable"
the top curve remains about 42 degrees and causes much less
pain than lumbar curve....

i hope Lenke's office can work things out for you to go ahead
with the surgery....

jess...& Sparky

[Confusedmom]

Gardenia,

In light of our discussion of BMP usage on the other thread, I am even more curious to know what this 25-page ruling from United said. I wonder if Bernie or United would send you a copy. I hope it doesn't have anything to do with this cancer scare/controversy. But I am curious whether the insurer is fighting the off-label use of BMP. My insurance company changed the year before my surgery, but previously was United. Kelly in Dr. Lenke's office told me that United was one of the most difficult ones to get approval from, but that they almost always worked it out one way or another.

Evelyn