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difficulty with insurance company

Paisius

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My wife was supposed to have back fusion surgery yesterday.  Less than 24 hours before, we found out that insurance has denied it as not medically necessary, even though her doctor says this is what she needs.  Her doctor is fighting their response, and so is she, but please pray that the rescheduled surgery for tomorrow at 2:30 PM ET happens.  Her pain is getting much worse and we need to get something done.  Thank you.
 

chris

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Lord have mercy!
 

Adela

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Lord have mercy!

Hang in there, this is what they do... I had spine surgery and after approving it they denied it so while I was recovering had to be fighting the insurance company and dealing with the hospital who wanted payment.  Even though I had the original letter proving someone said it would be covered, it took months to work its way through the system. I think this is standard operating procedures, someone must get a bonus for the number of claims they reject.  And, after another hospitalization, mistakes were made so I had to call and call and call and get things to be reprocessed.

If you can find their policy (maybe on their online website?) on what they deem medically necessary, look at the list and start gathering documented proof.  Chances are a different claims adjuster will look at it, but you should know first what must be documented in order for them to say it is medically necessary.  Unfortunately this is what you have to do, stay calm and work through the system.  We'll all be praying for you and your wife!
 

Seth84

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Lord have mercy!  Please keep us updated.
 
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I hope this doesn't come across as flippant, but I find that in such situations, angry letters written in a hyper-formal tone and vaguely threatening legal action tend to do the trick.

Lord, have mercy on your handmaiden!
 

Paisius

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It is a "colorful" insurance company who seems to have no one working for them but voice mail systems. :)

They denied the doctor's review, so she filed an emergency appeal, included what little info we had here at home to backup our position, and she emailed the coordinator (who hands it off to the neurosurgeon) an awesome letter showing peer-reviewed information as to why this surgery should be approved; pleading to his heart (she's stuck in bed 95% of the time and the pain meds don't work as well anymore), saying she will lose her job and not be able to attend her son's HS graduation in May (all of which is of course true); and that this surgery is going to have to be done eventually, so the surgeon was trying to avoid complications by doing too many surgeries and having so much scar tissue.  At the bottom of the letter, she mentioned we are willing to pursue all avenues necessary, including to the state, and also getting legal advice.  My wife used to be a paralegal student, so she has several contacts, and she's already working through that as she can be up and about.

We are *supposed* to have the results of her appeal late tomorrow afternoon (but you know how that goes), and the doctor is supposed to be urgently appealing as well, although we don't have an update on that yet.

Please continue to pray for us.  She has an appt w her surgeon on Wed to discuss the next steps (assuming none of this works), but she's starting to really give up hope.
 

Achronos

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Sorry if I asked what health insurance you have, personally I asked the question because I'm shopping for individual insurance myself.

Lord have mercy!
 

IsmiLiora

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Still praying, here. Lord have mercy. I hope something comes through for your wife.
 
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