Thursday, September 18, 2008

Insurance/Healthcare Thoughts

I've been struggling to get a patient's insurance company to give consent for a panniculectomy. I have not been successful. I have appealed the initial reject. It was rejected a second time. There reasoning:

Upon reviewing the submitted information, I have determined that at this time "Excision, excessive skin and subcutaneous tissue; abdomen, infraumbilical panniculectomy" is not a covered benefit under the benefit plan. This determination is based upon the following plan language, found on pages (s) 74 and 125 of the member's Certificate of Coverage or Summary Plan Description:

"Excluded ..... Cosmetic procedures, including cosmetic surgery expenses, supplies, appliances and drugs, except for reconstructive surgery to repair accidental injury

Cosmetic Procedures -- services are considered Cosmetic Procedures when they improve appearance without making an organ or body part work better. The fact that a person may suffer psychological consequences from the impairment does not classify surgery and other procedures done to relieve such consequences as a reconstructive procedure."

I thought I had made it clear, both times, that this proposed panniculectomy was to be done at the request of the patient's dermatologist as the patient's chronic skin rashes/infection in the lower abdominal skin roll could not be treated adequately with conservative methods. How is the treatment of the patient's skin infection/hygiene issues cosmetic?

It seems to me that this patient's insurance company is failing him. This seems to be a recurring theme in recent weeks in the blog world. Check out the recent post and comment section by TBTAM -- In Case You Were Wondering If Health Care is Broken.

Also check out When an MD says Yes and Insurance says NO by Healthcare Today, September 9, 2008

If a credentialed provider determines a specific course of action is reasonable for medical therapy it is amazing that insurance companies can countermand that judgment. Providers may be working as patient advocates, but clearly insurance companies are looking out for their own selfish bottom line. Not a new revelation as most of us would agree.

3 comments:

R.Wallis said...

Great Post! I understand this situation all too well. It happens all the time in my office.

mark's tails said...

Sadly, and not to sound too sarcastic, but its a crapshoot and the insurance co. is betting she won't be admitted to the hospital for sepsis and require a prolonged inpatient or ICU stay. Very, very frustrating.

Intransigentia said...

Unfortunately, I immediately thought the same thing mark did. Why bother paying for prevention if the worst case scenario isn't 100% likely to happen?