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Topic: Claim approved and then denied?

Forum: Employment, Insurance, and Other Financial Issues —

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Posted on: Aug 31, 2019 03:17PM

WC3 wrote:

I received a notice from my insurance company's utilization managment department saying the claim for my exchange surgery has been denied due to not being medically necessary (wrong because it was medically necessary and wrong because it's part of my reconstruction that they are required to cover by law).

Of course I discover this on a Saturday.

But I previously received the EOPS showing that they covered the exchange surgery.

Can they retroactively revoke an approved claim?


Dx 2018, IDC, Left, 3cm, Grade 3, ER+/PR+, HER2+ (FISH) Chemotherapy 5/31/2018 Carboplatin (Paraplatin), Taxotere (docetaxel) Surgery 11/14/2018 Lymph node removal: Left, Sentinel; Mastectomy: Left, Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery Reconstruction (left): Silicone implant; Reconstruction (right): Silicone implant Targeted Therapy Perjeta (pertuzumab) Targeted Therapy Herceptin (trastuzumab)
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Aug 31, 2019 10:52PM vlnrph wrote:

Yes, I've heard about this occurring. You should certainly fight back and perhaps report them to your state's insurance commissioner's office. Sometimes these complaints can be submitted on line. If yours is a consumer friendly department, government staff will investigate and possibly fine them for acting in bad faith.

Keep notes when you talk to someone and protect your right to appeal by filing a formal protest in writing. I wonder whether they are also going after your doctor's office for reimbursement of the previously paid claim...

Let us know how it goes. I'm afraid this tactic will become more prevalent in the future as companies look to increase profits. After all, the only way they make money is to not provide benefits!

IDC too! 🎻💊👪🐩 🇫🇮 🌹🦋 Rt MX+DIEP 4-2011; ALND 5-2011 d/t micromets; TC X 4; tamoxifen; lymphedema 9-2011; switch to letrozole 3-2014 for 1 yr; bone mets 8-2018: Zometa, rads to spine, Faslodex/Versenio Dx 3/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/25 nodes, ER+/PR+, HER2-
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Sep 1, 2019 02:37AM WC3 wrote:

vlnrph:

I definately plan to make some phone calls next week.

Dx 2018, IDC, Left, 3cm, Grade 3, ER+/PR+, HER2+ (FISH) Chemotherapy 5/31/2018 Carboplatin (Paraplatin), Taxotere (docetaxel) Surgery 11/14/2018 Lymph node removal: Left, Sentinel; Mastectomy: Left, Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery Reconstruction (left): Silicone implant; Reconstruction (right): Silicone implant Targeted Therapy Perjeta (pertuzumab) Targeted Therapy Herceptin (trastuzumab)
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Sep 1, 2019 10:18PM edwards750 wrote:

Idk if it’s legal for them to pull the rug out from under you but they do it all the time. I have BC/BS who initially approved paying for the Oncotype test that cost $5k and subsequently denied payment. Genomic Labs who conducted the test said they did that all the time and not to worry they would appeal. Never heard another word. That test was vital for me. It allowed me to dodge chemo.

We had another case where my DH needed to have a procedure that only an OON facility could perform. BC denied the claim - another $5k charge and we appealed and won so squeaky wheel gets the grease. Be persistent and relentless.

Diane

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Sep 1, 2019 10:43PM WC3 wrote:

edwards750:

My infusions were about $23,000 each so you would think they would rather pay $5,000 to see if chemo can be skipped. They make no sense sometimes.

Dx 2018, IDC, Left, 3cm, Grade 3, ER+/PR+, HER2+ (FISH) Chemotherapy 5/31/2018 Carboplatin (Paraplatin), Taxotere (docetaxel) Surgery 11/14/2018 Lymph node removal: Left, Sentinel; Mastectomy: Left, Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Hormonal Therapy Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery Reconstruction (left): Silicone implant; Reconstruction (right): Silicone implant Targeted Therapy Perjeta (pertuzumab) Targeted Therapy Herceptin (trastuzumab)
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Sep 4, 2019 07:23AM edwards750 wrote:

No they don’t WC3. In fact my BS associate said that very same thing when BC/BS pulled the rug out from under me in paying for the Oncotype test. Happy ending though eventually it got paid by them

Diane

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Sep 4, 2019 08:29AM - edited Sep 4, 2019 08:31AM by sweetp6217

Just my 2 cents, IMO, your "cancer team" at the hospital should have a coordinator that can get in touch with your insurance. Prior authorizations are handled by them and the surgeon's peeps, etc. Hope that helps.

P.S. insurance coding is key.

Dx 7/7/2017, IDC, Left, 2cm, Stage IIB, Grade 3, 1/2 nodes, HER2+ (FISH) Targeted Therapy 7/27/2017 Herceptin (trastuzumab) Chemotherapy 7/27/2017 Carboplatin (Paraplatin), Taxotere (docetaxel) Surgery 1/4/2018 Lumpectomy: Left; Lymph node removal: Sentinel, Underarm/Axillary Radiation Therapy 2/21/2018 Whole-breast: Breast, Lymph nodes Hormonal Therapy 4/14/2018 Femara (letrozole)
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Sep 4, 2019 08:41AM pingpong1953 wrote:

This stuff has been going on for years. Of course, they still take your premiums!

Dx 4/12/2017, DCIS/IDC, Right, 1cm, Stage IIA, Grade 3, 1/2 nodes, ER+/PR+, HER2- Surgery 5/2/2017 Lumpectomy: Right; Lymph node removal: Sentinel Chemotherapy 7/5/2017 Cytoxan (cyclophosphamide), Ellence (epirubicin), Fluorouracil (5-fluorouracil, 5-FU, Adrucil), Taxotere (docetaxel) Hormonal Therapy 12/8/2017 Femara (letrozole) Surgery 2/27/2018 Lymph node removal: Underarm/Axillary; Mastectomy: Right

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