Topic: insurance appeal

Hi,

I just got a denial from my carrier, today, for Dr. Allen/Levine. They are saying that I have a PS in Network who will do the proceedure.  Problem is that this ps will do an SGap but not simultaneously.  I'd have to have unil mast on one side and 3 months later go back to do the other side.  Can you believe that.  I'm not thrilled about doing this once never mind twice.  I'm filing an apeal on the basis that the ps in network does not perform the same proceedure because it is not simultaneous.    Why are the others not recommending the proceedure for you?  Does it have anything to do with not having enough abdom. fat?  because that's why I can't do DIEP. I think if you're persistant, eventually they will approve it.

GOOD LUCK!!!!  

thanks for the replies.  i was told i was too heavy and i am large breasted.  i am trying to lose about 10lbs before the surgery.  and i cannotunderstand why an insurance co would want to risk their money on complications.  so we'll see. i am putting the appeal together carefully.

I had to appeal for Drs Levine and Allen after being denied as well. It took two rounds, but I was prepared to physically go to wherever the folks who make these decisions were and flash my mangled chest if I had to. You have to be prepared to exhaust all possibilities, too, and not take "no" for an answer...

I agree with Anne about being as specific in your appeals as possible. Detail why you want to go with the surgeon/technique you've chosen. Keep in mind that Dr. Allen pioneered the DIEP and GAP proceedures and has done THOUSANDS of them, not just 10 or so that the in-network docs may have. Insurance companies are required to let you do the reconstruction of your choice, but I've found that if you want a specific, off-the-beaten-path type of recon done (IGAP, SCAP, DIEP for example), you'll need to say WHY - like for you, mwoodrowe, the fact that the in-network docs have said you're not a candidate is very good reason to try to go out of network with the best there is.

I would add, though, that you should try to follow up with a letter during every stage of the appeal process - even if round one is a generic form or a phone conversation. Know how your particular insurance company's appeal process works and stay on top of them about it - especially when it comes to the number of days they have to respond by, etc. I've found that when it comes to appeals, the squeeky wheel most definitely gets the oil.

All the best...

I am also trying to get a Diep and I am concerned that by the time I see the in network PS next Wed and then see the expert PS at the end of next week and then proceed with the fight with the insurance company - it will be about six weeks making it a total of 8 weeks after diagnosis to get the surgery done.  I am stage 1 but worry that it will advance with the time lapse.  I want the mastectomy/surgery at the same time.  Is any one else concerned with the time lapse?

Tricia

Fingers crossed for the appeal!!!

Tricia...talk w/ your oncologists and get their opinion.  For me I was first DCIS once I had  bilateral Mas I had 2mm of IDC within breast tissue then had idc in 3 out of 11 nodes...I did have immediate recon with expanders, but got an infection and had to have removed....I just had diep AUG 31 w/Dr. Levine.  I know it is fantastic to have one surgery, but ultimately in my opinion anyway, you want to get the cancer out...it is just shameful that when you wish to choose DIEP you have to fight with Insurance to have and expert surgeon...honestly, in the long run it will save Insurance companies to allow patients exceptions in this case it is such a sensitive surgery you would want someone very skilled doing it......it is going to take some real fighting out there to get this changed!!  See what your Doc's say and go with your intuition.....best of luck with  it all!!!  fists up!!!!

Tricia,

I was stage I and had to wait eight weeks.  All of my doctors agreed that it wouldn't make a difference, and it didn't.   Actually, my treatment has been the same as if I'd decided on prophylactic surgery and had never had breast cancer.   It was explained to me that my cancer had already been there for 5-7 years and a few extra weeks of waiting weren't going to harm me.

I did win on my 2nd appeal to my insurance company. The first letter was short, and they denied me.  For the second go-round I composed a very long letter to explain how challenging DIEP surgery is (it is coded by Medicare to be as complex as a kidney transplant), and also used some information I'd uncovered with regard to the in-network surgeon to explain why I was choosing to go with the out-of-network surgeon.   My insurance company actually ended up paying more than they would have to the in-network surgeon!