Is there any way to appeal health insurance denial from exclusion?
January 15, 2016 6:11 AM Subscribe
I have pretty significant chronic pain. One strategy my doctor suggested to deal with the pain was to get a breast reduction as a way of managing pain from a thoracic herniation. I was denied because it's a policy exclusion. But special snowflake details.
Yeah, it's a policy exclusion so I know it's going to be a long fight if it's even possible. I just do not have the money to out of pocket this, and can't foresee that changing since this put me out of work. Which leave me with appealing this. I have large breasts, not the largest but I'm also a small woman and they put a lot of strain on my body. I've just dealt with the headaches, neck and should pain, rashes and bad posture because that's just life.
Enter chronic, escalating pain about 4 years ago. No one knew the cause, and I'm not sure we've figured out all of it yet. I started with a diagnosis of fibromyalgia- I have leg pain, arm pain wrist issues, my thighs, hips buttocks. But the worst, the absolute worst is this band of pain that wraps around my chest. Right at the bra band area. Doctors discovered this past fall that I have a herniated disc that is protruding in my thoracic spine and pressing on the nerve root. They think it's only responsible for the rib cage pain, but apparently it falls right on that dermatome level, so are convinced that's the cause of the rib cage pain. 2 epidurals gave me about 50% relief for about 6 weeks. But I'm back to pain again. I go for another next week, but they're providing short term symptomatic relief, and even then, only some.
One particularly nasty trigger is a bra band. My rib cage is just insanely sensitive, and has progressively gotten more so since late summer 2012. I went from sports bras, which I stopped being able to tolerate, to a well fitted normal bra, to various "soft bras" including "stretchy" bras. I know they're terrible, but they were for a while all I could tolerate. Since the last epidural wore off, wearing one for a couple hours feels like I was punched in the back, with pain radiating around the ribs and finally below and behind my breasts. This pain can last for days. It's always there in some form, but so much worse if I try to wear a bra.
(I've also tried a few other things, longline bras, making a "wrap" for my breasts, which sort of works but puts the weight on my neck.)
Why do I try and wear a bra then? Well because not wearing one comes with its own pain issues. It seems to aggregate the nerve to, I think, only pulling, causing an increase in pain under the ribs. And that complicates neck and shoulder pain, and I can't help myself from hunching forward. Neck pain migrates to occipital headaches which progress to full blown nausea and vomiting migraines most of the time.
So there is all that. I can barely leave the house any more because movement is unrelenting pain. Even going braless, "bounce" just from walking is a considerable issue- it seems like I'm fighting the pain from my breasts one way or another.
My pain doctor and I discussed breast reduction as a way of reducing some of the symptoms. Thoracic herniations are a difficult and dangerous surgery; one that they won't do unless there is cord compression with neurological symptoms. So the idea is that breast reduction will help with reducing symptoms, as well as allowing me to wear non-constructive support, or even go without. My other doctors are on board. I saw a plastic surgeon, who thought I'd be a great candidate before the thoracic disc issue- that last piece should guarantee it.
And that's when I find out that there is a policy exclusion for any breast reductions not associated with cancer. I'm both livid and really feel terrible because I thought I had a chance for some relief. I'm livid because sure, let's throw another women's health under the bus.
And that is where I'm wondering if it isn't possible to get the insurance to reverse their decision. Yes, it's excluded, but the expected outcome is to reduce the amount of pain that a part of the body that is covered is causing.
I strongly suspect that isn't enough to convince an insurance company to cover it. But if there is anything I can and should do to convince them, please speak up.
A few minor notes, I've found a bunch of women online with similar thoracic herniations, and they all have similar rib/breast/bra issues, most being large breasts and bra problems. I've not been able to find anyone who was post breast reduction to see if it helped.
I am overweight, but just a little with a bmi of 26. I'm working to lose weight for general health. But it's hard with such little daily activity. Exercise is nearly impossible, and that's always been how I lose weight the best. I've been losing it, slowly. I've lost and gained weight in the past and lose relatively little breast mass, so am doubtful this will help with that. The year I the rib pain started, I was the lowest weight I had been in a long time, so I know that it's not caused by the weight.
From what I understand, symptomatic thoracic herniations are relatively rare. Compounding that is I have no idea how I did it. It's usually associated with an injury, and nothing comes to mind. I fell hard about 10 years ago, but aside from a bruised ego, was fine and it didn't include any torsion normally associated with the injury. It's probably the "worst" I've done to myself.
I talked to the insurance company twice, once via chat and once via the phone who both told me that if medically necessary, a breast reduction would be allowed, and then quoted the glossary which included discussion of breast reconstruction being available for "physiological functional impairment or cancer". They both told me that is what breast reduction would fall into. I have since been told this is wrong. I am going to guess I can't use this to twist the arm of insurance, but thought I'd mention it in case there was a way to use it. Both reps did state that I'd have to to go through a process of pre-determination to really assess my eligibility. I had already been denied at that point and had told both I was just trying to find clarification and what the language of the policy said about the exclusion. They noted there was an exclusion, but suggested that the statement that the physiological functional impairment or cancer would trump that. I've since seen the coverage document and I don't think so, and the insurance eventually confirmed the denial and that the exclusion trumps all.
Apparently breast reduction exclusions are fairly common in health insurance policies and I'm really angry about this because this is more anti-woman shit. This is apropos of nothing other than my rage as I found this out a few days after this thread.
Yeah, it's a policy exclusion so I know it's going to be a long fight if it's even possible. I just do not have the money to out of pocket this, and can't foresee that changing since this put me out of work. Which leave me with appealing this. I have large breasts, not the largest but I'm also a small woman and they put a lot of strain on my body. I've just dealt with the headaches, neck and should pain, rashes and bad posture because that's just life.
Enter chronic, escalating pain about 4 years ago. No one knew the cause, and I'm not sure we've figured out all of it yet. I started with a diagnosis of fibromyalgia- I have leg pain, arm pain wrist issues, my thighs, hips buttocks. But the worst, the absolute worst is this band of pain that wraps around my chest. Right at the bra band area. Doctors discovered this past fall that I have a herniated disc that is protruding in my thoracic spine and pressing on the nerve root. They think it's only responsible for the rib cage pain, but apparently it falls right on that dermatome level, so are convinced that's the cause of the rib cage pain. 2 epidurals gave me about 50% relief for about 6 weeks. But I'm back to pain again. I go for another next week, but they're providing short term symptomatic relief, and even then, only some.
One particularly nasty trigger is a bra band. My rib cage is just insanely sensitive, and has progressively gotten more so since late summer 2012. I went from sports bras, which I stopped being able to tolerate, to a well fitted normal bra, to various "soft bras" including "stretchy" bras. I know they're terrible, but they were for a while all I could tolerate. Since the last epidural wore off, wearing one for a couple hours feels like I was punched in the back, with pain radiating around the ribs and finally below and behind my breasts. This pain can last for days. It's always there in some form, but so much worse if I try to wear a bra.
(I've also tried a few other things, longline bras, making a "wrap" for my breasts, which sort of works but puts the weight on my neck.)
Why do I try and wear a bra then? Well because not wearing one comes with its own pain issues. It seems to aggregate the nerve to, I think, only pulling, causing an increase in pain under the ribs. And that complicates neck and shoulder pain, and I can't help myself from hunching forward. Neck pain migrates to occipital headaches which progress to full blown nausea and vomiting migraines most of the time.
So there is all that. I can barely leave the house any more because movement is unrelenting pain. Even going braless, "bounce" just from walking is a considerable issue- it seems like I'm fighting the pain from my breasts one way or another.
My pain doctor and I discussed breast reduction as a way of reducing some of the symptoms. Thoracic herniations are a difficult and dangerous surgery; one that they won't do unless there is cord compression with neurological symptoms. So the idea is that breast reduction will help with reducing symptoms, as well as allowing me to wear non-constructive support, or even go without. My other doctors are on board. I saw a plastic surgeon, who thought I'd be a great candidate before the thoracic disc issue- that last piece should guarantee it.
And that's when I find out that there is a policy exclusion for any breast reductions not associated with cancer. I'm both livid and really feel terrible because I thought I had a chance for some relief. I'm livid because sure, let's throw another women's health under the bus.
And that is where I'm wondering if it isn't possible to get the insurance to reverse their decision. Yes, it's excluded, but the expected outcome is to reduce the amount of pain that a part of the body that is covered is causing.
I strongly suspect that isn't enough to convince an insurance company to cover it. But if there is anything I can and should do to convince them, please speak up.
A few minor notes, I've found a bunch of women online with similar thoracic herniations, and they all have similar rib/breast/bra issues, most being large breasts and bra problems. I've not been able to find anyone who was post breast reduction to see if it helped.
I am overweight, but just a little with a bmi of 26. I'm working to lose weight for general health. But it's hard with such little daily activity. Exercise is nearly impossible, and that's always been how I lose weight the best. I've been losing it, slowly. I've lost and gained weight in the past and lose relatively little breast mass, so am doubtful this will help with that. The year I the rib pain started, I was the lowest weight I had been in a long time, so I know that it's not caused by the weight.
From what I understand, symptomatic thoracic herniations are relatively rare. Compounding that is I have no idea how I did it. It's usually associated with an injury, and nothing comes to mind. I fell hard about 10 years ago, but aside from a bruised ego, was fine and it didn't include any torsion normally associated with the injury. It's probably the "worst" I've done to myself.
I talked to the insurance company twice, once via chat and once via the phone who both told me that if medically necessary, a breast reduction would be allowed, and then quoted the glossary which included discussion of breast reconstruction being available for "physiological functional impairment or cancer". They both told me that is what breast reduction would fall into. I have since been told this is wrong. I am going to guess I can't use this to twist the arm of insurance, but thought I'd mention it in case there was a way to use it. Both reps did state that I'd have to to go through a process of pre-determination to really assess my eligibility. I had already been denied at that point and had told both I was just trying to find clarification and what the language of the policy said about the exclusion. They noted there was an exclusion, but suggested that the statement that the physiological functional impairment or cancer would trump that. I've since seen the coverage document and I don't think so, and the insurance eventually confirmed the denial and that the exclusion trumps all.
Apparently breast reduction exclusions are fairly common in health insurance policies and I'm really angry about this because this is more anti-woman shit. This is apropos of nothing other than my rage as I found this out a few days after this thread.
Health insurance companies are (for good reason) very conservative about approving as medically necessary procedures which are mostly used for cosmetic reasons.
Your appeal will need to be in writing and supported by affidavits from your doctors which at length explain the nature of your condition, the costs of the treatments that you are presently undergoing, and their confidence that breast reduction will remedy the medical condition (ideally supported by references to research).
The red flags that I can see are -- your doctor's apparent uncertainty that the surgery will have the desired medical benefit, and your history of fibromyalgia, which tends to call all other pain complaints into question especially when you are asking for coverage for expensive (usually) cosmetic surgery.
posted by MattD at 6:54 AM on January 15, 2016 [1 favorite]
Your appeal will need to be in writing and supported by affidavits from your doctors which at length explain the nature of your condition, the costs of the treatments that you are presently undergoing, and their confidence that breast reduction will remedy the medical condition (ideally supported by references to research).
The red flags that I can see are -- your doctor's apparent uncertainty that the surgery will have the desired medical benefit, and your history of fibromyalgia, which tends to call all other pain complaints into question especially when you are asking for coverage for expensive (usually) cosmetic surgery.
posted by MattD at 6:54 AM on January 15, 2016 [1 favorite]
Do you have written copies of your contract? I'd start combing through that, possibly with free legal aid, and send messages to your insurance company in writing. You've done a pretty good job of communicating the information here, but you don't seem to have a firm understanding on your own of what's actually written in the contract -- you're relying on what someone from the insurance company is telling you over the phone, which may well be correct, but may not take into account all the information you have or may not be complete.
It sounds also like advocating for this will involve making a convincing case that this is not "cosmetic". Again, you're doing a pretty good job of this in the text you've already written, but I think there are probably some other great arguments and phrasings out there that will help you make a really strong case in your next communication.
Good luck.
posted by amtho at 7:17 AM on January 15, 2016 [1 favorite]
It sounds also like advocating for this will involve making a convincing case that this is not "cosmetic". Again, you're doing a pretty good job of this in the text you've already written, but I think there are probably some other great arguments and phrasings out there that will help you make a really strong case in your next communication.
Good luck.
posted by amtho at 7:17 AM on January 15, 2016 [1 favorite]
I successfully appealed to have a breast reduction covered about ten years ago. My plastic surgeon basically wrote up all the reasons this was medical and not cosmetic and submitted it to the insurance company on my behalf. I recall there actually being some sort of guidelines for him to show that I was a good candidate for a breast reduction for pain relief. I specifically remember that they had to show that I had a severe level of ptosis (sag) for my age/weight. Your surgeon probably has experience with these type of denials and should be able to help.
posted by galvanized unicorn at 7:37 AM on January 15, 2016 [1 favorite]
posted by galvanized unicorn at 7:37 AM on January 15, 2016 [1 favorite]
If the insurance route doesn't work, have you considered medical tourism? Obviously not ideal and you'd have to do extra due diligence, but going to a place like Thailand might make it affordable out of pocket...
posted by three_red_balloons at 7:56 AM on January 15, 2016 [1 favorite]
posted by three_red_balloons at 7:56 AM on January 15, 2016 [1 favorite]
Talk to your doctors. You plastic surgeon has done this before and should work with you to get it authorized. They probably even have someone on staff who's only job is to get pre-authorizations.
You may have to go through a screen process that includes conservative treatment of the spinal/rib pain (think physical therapy) and fail before the insurance company with authorize the treatment, but keep fighting.
My wife had a reduction about 10 years ago for many of the same complaints as you are having (minus the thoracic disc). Her PCP referred her to a plastic surgeon who did a thorough history and exam and took (neck down) pictures to include in the pre-authorization paperwork. It only took about 3 weeks to get approval.
If that does not work, then your insurance company should have an appeal process. Finally, you can work with your state insurance commissioner's office if they deny the appeal.
If your surgeon is not helpful with the pre-authorization, then find a new surgeon.
posted by Broken Ankle at 7:56 AM on January 15, 2016 [1 favorite]
You may have to go through a screen process that includes conservative treatment of the spinal/rib pain (think physical therapy) and fail before the insurance company with authorize the treatment, but keep fighting.
My wife had a reduction about 10 years ago for many of the same complaints as you are having (minus the thoracic disc). Her PCP referred her to a plastic surgeon who did a thorough history and exam and took (neck down) pictures to include in the pre-authorization paperwork. It only took about 3 weeks to get approval.
If that does not work, then your insurance company should have an appeal process. Finally, you can work with your state insurance commissioner's office if they deny the appeal.
If your surgeon is not helpful with the pre-authorization, then find a new surgeon.
posted by Broken Ankle at 7:56 AM on January 15, 2016 [1 favorite]
Best answer: What you're looking for is not just an appeal but a 'peer to peer' review of your case. Your doctor will have to get on the phone with one of the doctors at the insurance company and discuss your case. Ask them the steps and then repeat back to them so that you have it clear. Make sure that you are clear the time line - usually a written appeal is something like 14 business days to review AFTER they've received it and only then are they willing to do a peer to peer. This is when it's not a regular pre-authorization situation like a regular run of the mill surgery (that wouldn't be subject to refusal).
Whether it's your pain management doctor, plastics doctor or whichever one has the most compelling information/documentation, that's up to you. But that's what's worked for me in order to get my insurance to cover procedures they normally wouldn't. FWIW, I have United Healthcare.
Also, get a good paper trail going. Times/dates/names of people you contact. Most importantly, your case number. Get it in the beginning of the conversation and ask them again at the end (along w spelling - ask for direct contact info/extension numbers). That way they will be aware that you are noting what you've discussed. I can't begin to tell you how much red tape I've gone through with stuff going to wrong departments and just sitting there unacknowledged.
Good luck!
posted by dancinglamb at 8:10 AM on January 15, 2016 [2 favorites]
Whether it's your pain management doctor, plastics doctor or whichever one has the most compelling information/documentation, that's up to you. But that's what's worked for me in order to get my insurance to cover procedures they normally wouldn't. FWIW, I have United Healthcare.
Also, get a good paper trail going. Times/dates/names of people you contact. Most importantly, your case number. Get it in the beginning of the conversation and ask them again at the end (along w spelling - ask for direct contact info/extension numbers). That way they will be aware that you are noting what you've discussed. I can't begin to tell you how much red tape I've gone through with stuff going to wrong departments and just sitting there unacknowledged.
Good luck!
posted by dancinglamb at 8:10 AM on January 15, 2016 [2 favorites]
Response by poster: Just to clarify a couple things- I did not have the coverage document when I talk to the insurance company's customer support. Since that time, I have received a copy and my read of it is that it is excluded. If I understand correctly, exclusions are dead stops "we do not cover this medical procedure" period, done frequently to save money. It also includes exclusions for weight management programs, gastric bypass, various foot surgeries such as ingrown nails. (And example, not all items). It is written as a standard coverage document, with exclusions that are there to lower the price for the company that is paying for the insurance, in this case my husband's employer.
There is no question of medical necessity, my understanding is they did not even review it for medical necessity, the insurance company saw breast reduction and that was a hard no, so they never got to the point of determining that. I believe this may be do to case law where a woman won against an insurance company with an exclusion- the insurance found her breast reduction medically necessary but refused to pay for it because it was excluded. The court determined because they had determined it was medically necessary, they had an obligation to pay for it. Sort of. Case here. There were other factors.
I'm not sure it would be possible for a peer to peer review because they don't even get as far as a doctor at the insurance reviewing it.
I talked to the plastic surgeon's office, they said exclusions like this are becoming more common and they do not help with appeals if the denial reason is an exclusion. If it's because of another finding (say the insurance company was arguing that it just wasn't medically necessary), then they do help. I could see another plastic surgeon, but the surgeon's policy seems reasonable to me. I am certain this is a no to extreme long shot- I'm banking on extreme long shot because that's my only option. After coming in to express my frustrations, my pain therapist thought I might be able to make the case that by not approving the breast reduction, the company will pay more in the long term. But it was a suggestion that wasn't based on experience, only on giving me something to try.
I've already done physical therapy and occupational therapy, I should have included that. I tried pt repeatedly for about a year and a half, but ended up in too much pain to continue until my doctor recommended we stop pushing because it wasn't working and I was getting worse, not better. There are not many conservative options left to me; and the epidural reduced pain but did not make it go away, nor did it last long enough as the number I can have per year is limited. There is the possibility of nerve blocks- the doctor's office that did the epidurals and did the diagnosing didn't seem to think they would help- I don't recall the reason why, but I can ask on Monday.
I should state, I'm not entirely sure I have fibromyalgia- I think it was a diagnosis that doctors threw at me when they couldn't figure out where my pain was coming from. I'm missing many of the hallmarks of fibro- I'm not particularly tender to the touch nor do I have the tender points, but the 2011 standards threw those out. I don't know where the rest of the pain is coming from. I do know that the epidurals also helped with the lower body symptoms. There is no cord compression though, so it should not have. Doctor's don't have a good answer except ¯\_(ツ)_/¯.
I have not receive the written denial yet- I assume it just has not gotten here yet as the doctor's office told me Monday.
I know that the plastic surgeon submitted the information from my pain management doctor to the insurance company. I'll have to find out what that was, and see what I need to do to get him to write an affidavit, along with if the other doctors I see feel that way. (They were supportive of it, but we didn't have a "this is why they think it will help" conversation.)
posted by [insert clever name here] at 10:10 AM on January 15, 2016
There is no question of medical necessity, my understanding is they did not even review it for medical necessity, the insurance company saw breast reduction and that was a hard no, so they never got to the point of determining that. I believe this may be do to case law where a woman won against an insurance company with an exclusion- the insurance found her breast reduction medically necessary but refused to pay for it because it was excluded. The court determined because they had determined it was medically necessary, they had an obligation to pay for it. Sort of. Case here. There were other factors.
I'm not sure it would be possible for a peer to peer review because they don't even get as far as a doctor at the insurance reviewing it.
I talked to the plastic surgeon's office, they said exclusions like this are becoming more common and they do not help with appeals if the denial reason is an exclusion. If it's because of another finding (say the insurance company was arguing that it just wasn't medically necessary), then they do help. I could see another plastic surgeon, but the surgeon's policy seems reasonable to me. I am certain this is a no to extreme long shot- I'm banking on extreme long shot because that's my only option. After coming in to express my frustrations, my pain therapist thought I might be able to make the case that by not approving the breast reduction, the company will pay more in the long term. But it was a suggestion that wasn't based on experience, only on giving me something to try.
I've already done physical therapy and occupational therapy, I should have included that. I tried pt repeatedly for about a year and a half, but ended up in too much pain to continue until my doctor recommended we stop pushing because it wasn't working and I was getting worse, not better. There are not many conservative options left to me; and the epidural reduced pain but did not make it go away, nor did it last long enough as the number I can have per year is limited. There is the possibility of nerve blocks- the doctor's office that did the epidurals and did the diagnosing didn't seem to think they would help- I don't recall the reason why, but I can ask on Monday.
I should state, I'm not entirely sure I have fibromyalgia- I think it was a diagnosis that doctors threw at me when they couldn't figure out where my pain was coming from. I'm missing many of the hallmarks of fibro- I'm not particularly tender to the touch nor do I have the tender points, but the 2011 standards threw those out. I don't know where the rest of the pain is coming from. I do know that the epidurals also helped with the lower body symptoms. There is no cord compression though, so it should not have. Doctor's don't have a good answer except ¯\_(ツ)_/¯.
I have not receive the written denial yet- I assume it just has not gotten here yet as the doctor's office told me Monday.
I know that the plastic surgeon submitted the information from my pain management doctor to the insurance company. I'll have to find out what that was, and see what I need to do to get him to write an affidavit, along with if the other doctors I see feel that way. (They were supportive of it, but we didn't have a "this is why they think it will help" conversation.)
posted by [insert clever name here] at 10:10 AM on January 15, 2016
This is a longer term plan, but if all else fails with your current insurance company, how about dropping your husband's insurance and buying insurance on the marketplace during the next open enrollment, specifically choosing a plan that does not have this exclusion? I realize that would be a huge pain, but if you really feel this is a life-altering, medically necessary thing for you, it might be the way to go.
posted by rainbowbrite at 10:21 AM on January 15, 2016 [3 favorites]
posted by rainbowbrite at 10:21 AM on January 15, 2016 [3 favorites]
Was also going to suggest buying a new plan on the Marketplace that would cover this. Open enrollment ends January 31 for plans starting March 1 -- after that you have to wait until the fall to enroll for plans starting at the beginning of next year. So if you think you might like to do that, hurry.
posted by Jacqueline at 7:33 PM on January 15, 2016
posted by Jacqueline at 7:33 PM on January 15, 2016
Response by poster: Oceano, you are my hero. I don't know if this will work, but I'm about half way through and it's the best of any thing I've seen so far.
posted by [insert clever name here] at 10:27 PM on January 16, 2016
posted by [insert clever name here] at 10:27 PM on January 16, 2016
Best answer: I looked at oceano's link and it's pretty interesting. Here are some excerpts (just in case that story gets deleted and/or there are keywords here that get a search hit). I have no idea how well this would work really, not a lawyer, and I don't know if the author is a lawyer.
posted by amtho at 7:58 AM on January 30, 2016
On the face of it, none of the insurers in my forty-four cases would ever have had to pay a dime for any of these treatments. I believe that the reason that they do pay—after being severely intimidated by my written document—is the unwritten contract.direct link to the author's site (she is selling a book)
Nobody speaks of the unwritten contract, but insurance companies invoke it all the time—particularly in their promotional materials. Every time your insurer uses words meant to make you feel safe and cared-for, they portray themselves as keepers of this contract.
“You are in good hands with Acme Insurance.”
“We are the Rapid Response Resolution Team.”
“The name of our company is Neighborhood Health United.”
posted by amtho at 7:58 AM on January 30, 2016
This thread is closed to new comments.
There should be a formal procedure for challenging a denial. Can you find that in the policy? Had you received a formal, written denial yet?
posted by metasarah at 6:33 AM on January 15, 2016