General Discussion
In reply to the discussion: This message was self-deleted by its author [View all]Ms. Toad
(34,060 posts)I'll give you enough details of a couple of examples sp that you can at least verify the condition and the difficulty of getting coverage at the time.
I have VTOS (upper extremity DVT), which dates to 1988. The first time I spent a month in the hospital because that was the only option for stabilizing on anticoagulation therapy before being discharged on warfarin. - normally the process of balancing the two anti-coagulation medications takes 5-7 days; my body was stubborn. The second flare, 1998, low molecular weight heparin (Lovenox) was developed - but was only approved for clot prevention in connection with surgery - not as a treatment for clotting disorders. The choice was spending several days in the hospital, or convincing the insurance company to cover outpatient use of Lovenox. With my doctor's assistance, they insurance companies were convinced to allow me the (then) experimental treatment.
Here's a 1999 article about the early reported use of it for outpatient treatment: Savage KJ, Wells PS, Schulz V, Goudie D, Morrow B, Cruickshank M, et al. "Out-patient use of low molecular weight heparin (dalteparin) for the treatment of deep vein thrombosis of the upper extremity." Thromb Haemost. 1999;82:100810. There was also an ER episode around the same time "ripped from the headlines' as another show likes to say, in which the more common outcome - denial of coverage - was the outcome. That study of 46 patients was published almost a year and a half after my insurance company was convinced to allow me to use it for that condition as an outpatient. And, a 1999 article which references 12/31/1998 FDA approval for marketing the use of enoxaparin for outpatient use for treatment of uncomplicated DVT - 7 months after my insurance company was convinced to pay for it.
Here is a link to a separate mention of my first rib resection which was done to treat the same problem more recently - next to last paragraph. I obviously must have planted it contemplating just this conversation. Feel free to confirm that first rib resection is the current favored treatment for VTOS.
Another minor victory in the same time frame - the pathology costs relating to removing a mole displaying pre-cancerous traits were covered, but the excision was denied. They routinely denied all mole removal "cosmetic surgery." I didn't have to get the doctors involved in that one - I just challenged them about whether they denied coverage for the surgical removal of breast tissue in to examine the tissue associated with apparently pre-cancerous changes as cosmetic breast reduction surgery. Kind of surprised they bought that one as easily as they did, but they did.
Finally, if you have had many encounters with surgery and insurance, you are aware (or if not you can easily verify) that anesthesiologists are entities unto themselves - and fairly frequently not covered by the same insurance policies as the hospitals in which they work. I had an emergency appendectomy, and the anesthesiologists were considered "out of network," even though the hospital was "in network." The closest "in network" anesthesiologists were more than 50 miles away - and all out of network care required advance approval. Despite not having advance approval, they ultimately granted my appeal because of the emergency nature of the surgery, combined with the lack of disclosure by the hospital that they were using an anesthesia team which was out of network. (Here's an article) which specifically mentions this issue with anesthesiologists
Just 3 of the more generic examples of the many appeals I have won. Sorry - I'm not posting documentation, but you should be able to at least verify that they are the kind of problems which routinely crop up with insurance that are either prohibited by the policy, or beyond the language of the policy.