Medical proceedure is very nescessary but insurance refuse to cover it. How can I appeal?

Question

any one out there famliar with or work with insurance companies on arbitration of a reconstructive proceedure?
United Health Care has denied two seperate claims to repair my severe belly button hernia and diastasis( separation of the abdominal rectus muscles) due to trauma of multiple pregnicies (3) and My ab muscles are mot protecting my intestins OR my abdominal decending aorta due to the CT scan results. I TRIED to get a general surgeon to do it, but they say only a cosmetic doc does this type of reconstruction... Very similar to a tummy tuck... but it is NOT. Insurance denied coverage for it EVEN though 4 DIFFERENT DOCTORS say I shouldnt sit on this too long for A small blow or kick from the kids could cause intestinal tearing causing me to become septic, the intestins could come through the belly button, and I need my muscle wall closed up ASAP. Docs have sent leters to company stating in great detail how NECESSARY this is but they still refuse to cover they think its for cosmetic reasons. If I arbitrate it, 1st,... how... 2nd, what else could i say to get them to understand??

Where can i find Proof so i can mail them that this indeed is necessary and by far not cosmetic for me. I have 4 different docs all saying the very same thing on how dangerous it is if i dont get it repaired. I have NO money for a proceedure like that. If i were to ATTEMPT To write an arbitration letter... how would ya word it? ANy one out there with any advise that can help would be really be appreciated. Thanks in advance.

Answer 1

The issue here is not whether it is necessary for you. The issue is whether the procedure is covered under your policy.

Unless you can show to United Healthcare that this procedure is covered, you are on your own. The issue of "need" is irrelevant. If a procedure is defined in the covering policy as cosmetic surgery, then it is NOT covered, regardless of whether it is elective or needed.

Can you imagine how many folks would find a doctor to certify that their 'cosmetic surgery' is needed if insurers always covered such surgeries based upon 'need' ?

This is the reality of the insurance world. Specific situations are covered if they crop up, and others are not, based upon what language is in the policy provided and paid for. Hundreds of folks who truly NEED a heart transplant do not get it paid for under their coverage because it is specifically excluded under the policy. Such exclusions are generally placed in the policy in order to keep the policy premium lower for the company providing the policy.

Answer 2

according to the american society of plactic surgeons... the procedure you're describing is COSMETIC... It will not be covered. They will probably deny any appeal you submit. You will probably need to rethink the procedure. Hernia repair is covered. If you need abdominal wall repair in conjunction with the hernia surgery, that'll probably be covered as well... but, the diastasis recti is not medically necessary.... It is part of a normal tummy tuck... and has nothing to do with hernia repair.

They statement in the pdf file in the link below states a hernia repair, that includes abdominal wall repair is medical... BUT, a diastasis recti is purely cosmetic. So, that's the problem you're encountering.

Talk to your doctor, ans ask if you are a candidate for hernia repair. good luck

Answer 3

My sister in law had a procedure done after her 2nd child that seems similar to this (repairing of the belly button hernia). I have emailed her to find out whether she had insurance cover it and how she went about it. Her husband is a surgery resident so maybe he'll have some ideas/suggestions as well. I'll be getting back to you as soon as I hear from her, just wanted to let you know someone was thinking about you!

Answer 4

it might just have to end up in a lawsuit. the reason that the insurance company will not agree to this is because they are in business to make $ not to give it away. you pay into an account for who knows how long and never get anything in return other than a slimmer wallet its sad to say. outside of lawsuit best thing to do is make a friend in canada and use thier address and get medical help that way. the movie SICKO by michael moore addresses this whole issue and its a sad but true world we live in., i have had the opportunity to see this when it was posted on myspace, something everyone needs to see.

Answer 5

Your first step is to call the insurance ASAP and ask for their specific appeals process - including a contact name or department, their address, phone and fax number.

Contact these doctors and ask them to write you letters of medical necessity - providing ANY documentation (especially xrays or anything similar showing the damage.)

Send all this stuff together with your letter of appeal to the insurance - keep copies for yourself, and follow up with the plan within a week or ten days after you send it - to check status of the appeal.

Good luck!!

Answer 6

Your PROOF is letters from those four different doctors that state this is medically necessary, and then they need to list the reasons WHY it's medically necessary.

Just send them in with the request for appeal.