So I've written before about my insurance battles on behalf of my daughter with stage 4 endometriosis.
1. When she was first diagnosed in August 2013, after having surgery for an ovarian cyst and the doctor saw what a mess she was inside, the in-network surgeon wanted her referred to Dr. Camran Nezhat, THE world's expert (yeah, at least really good) on laparoscopic endometriosis surgery. Then a battle ensued, because he was out-of-network for my daughter's self-funded Aetna HMO. The utter and total bullshit that we went through to get her an appointment with him (it took two months of them "losing" the requests for pre-authorization, etc., which ended up requiring a 4 way phone call with Aetna, my daughter's reproductive endocrinologist who wanted her to see Dr. N, her PCP who was clueless but officially had to be the one to make the request, and Dr. N's office), and then to find out AFTERWARDS that they hadn't pre-approved two types of special ultrasounds that were REQUIRED for the intake appointment - and they refused to pay for the most expensive one, of course.
2. Then, she had to be prescribed a six week course of hormones that are ALSO used in IVF - so another battle.
3. Then another battle for getting her surgery approved, by Dr. N at Stanford Hospital (out of network).
4. The surgeon couldn't complete the surgery in one session, there were so many plaques, plus she needed additional procedures to remove a uterine septum and several fibroids - he got most of the septum but had to stop because she was bleeding too much. His recommendation was to FIRST do egg harvesting, because she was at so much risk of losing her ovaries from the recurring cysts (actually, endometriomas) that were destroying her ovaries.
5. Then came a monumental battle with Aetna, with them insisting it was an excluded procedure for being assisted reproductive technology, and us arguing that it was preventive care, to PRESERVE her fertility during treatment, since she just wanted to harvest her eggs.
6. That battle raged for almost two years. During that time, we got her medical group to do the first procedure at a very reduced rate, including donated meds. Aetna (probably unintentionally) paid for some of it (U/S that they didn't realize were part of the retrieval procedure), and even the anesthesiology for some reason. But it left an over $10K bill (without the discount).
7. The procedure itself only yielded 6 eggs. So she needed another procedure. In the meantime, she lost her job, gained a serious boyfriend, and got a CoveredCA plan with BS of CA that I thought might be able to be forced to cover the procedure.
8. Finally, just before the second procedure was scheduled, Aetna - I guess tired of my repeated threats, filings with ERISA, etc. - decided to "make and exception" due to "a procedural error" on their part (agreeing to let us have an external medical review and then rescinding it), and they paid the $10K.
9. In the meantime, as the next (unapproved) procedure was coming up, BS of CA somehow convinced the CA Dept. of Managed Health Care that the procedure was contractually excluded, even though it was for the purpose of preserving her fertility during treatment for a covered disease. Fuckers.
10. This time, however, the reproductive endocrinologist convinced Jess that if she was serious about her b/f, they should freeze embryos, rather than eggs, because they freeze and thaw better and the long term pregnancy rate per harvested egg is better. So they did, and I have 5 grandbabies on ice.
11. I should also say that after I explained the situation to him, the class action lawyer who took on the insurance companies in CA for making them cover reconstructive surgery - and he's won 3 of those cases so far - asked me to send him all the materials about what happened to my daughter with BS of CA. I hope my daughter ends up the named plaintiff in this one.
12. But back to her. The next step - which has been on hold for 2 years while all this nonsense went on - is to put her on Lupron again, only this time for 6 miserable months, and then operate again. Which means - another insurance fight to force BS of CA to give her a referral to Dr. N again - she has a PPO, but she should NOT have to pay out-of-network charges and a separate deductible to see a specialist that they don't have in-network.
13. So I wrote a long-ass letter for her reproductive endocrinologist to use in requesting pre-authorization for the next referral to Dr. N, who needs to see her before re-ordering the Lupron and setting up for a surgery down the road. It took forever (to me) for my daughter to take care of this - I think she's feeling a bit equivocal about the Lupron treatment while looking for a new job, which she knows will require a time-sensitive surgery and recovery. But she finally sent it in.
14. She heard from the RE today - with my letter, BS of CA approved her appointment with Dr. N without a fight! I'm flabbergasted! Let's hope the appointment doesn't have the same issues, nor the prescription for the Lupron.
15. I'm sure there will be more insurance fun along the way, but I am hoping that this second surgery will go smoothly, be definitive and her last, and she can get on with her life. And maybe try to make me some grandbabies soon, however that happens.
16. And I hope the class action attorney nails BS of CA for excluding a medically necessary surgery that was NOT merely for the purpose of delaying pregnancy, but for preserving her fertility while she undergoes these further treatments.
1. When she was first diagnosed in August 2013, after having surgery for an ovarian cyst and the doctor saw what a mess she was inside, the in-network surgeon wanted her referred to Dr. Camran Nezhat, THE world's expert (yeah, at least really good) on laparoscopic endometriosis surgery. Then a battle ensued, because he was out-of-network for my daughter's self-funded Aetna HMO. The utter and total bullshit that we went through to get her an appointment with him (it took two months of them "losing" the requests for pre-authorization, etc., which ended up requiring a 4 way phone call with Aetna, my daughter's reproductive endocrinologist who wanted her to see Dr. N, her PCP who was clueless but officially had to be the one to make the request, and Dr. N's office), and then to find out AFTERWARDS that they hadn't pre-approved two types of special ultrasounds that were REQUIRED for the intake appointment - and they refused to pay for the most expensive one, of course.
2. Then, she had to be prescribed a six week course of hormones that are ALSO used in IVF - so another battle.
3. Then another battle for getting her surgery approved, by Dr. N at Stanford Hospital (out of network).
4. The surgeon couldn't complete the surgery in one session, there were so many plaques, plus she needed additional procedures to remove a uterine septum and several fibroids - he got most of the septum but had to stop because she was bleeding too much. His recommendation was to FIRST do egg harvesting, because she was at so much risk of losing her ovaries from the recurring cysts (actually, endometriomas) that were destroying her ovaries.
5. Then came a monumental battle with Aetna, with them insisting it was an excluded procedure for being assisted reproductive technology, and us arguing that it was preventive care, to PRESERVE her fertility during treatment, since she just wanted to harvest her eggs.
6. That battle raged for almost two years. During that time, we got her medical group to do the first procedure at a very reduced rate, including donated meds. Aetna (probably unintentionally) paid for some of it (U/S that they didn't realize were part of the retrieval procedure), and even the anesthesiology for some reason. But it left an over $10K bill (without the discount).
7. The procedure itself only yielded 6 eggs. So she needed another procedure. In the meantime, she lost her job, gained a serious boyfriend, and got a CoveredCA plan with BS of CA that I thought might be able to be forced to cover the procedure.
8. Finally, just before the second procedure was scheduled, Aetna - I guess tired of my repeated threats, filings with ERISA, etc. - decided to "make and exception" due to "a procedural error" on their part (agreeing to let us have an external medical review and then rescinding it), and they paid the $10K.
9. In the meantime, as the next (unapproved) procedure was coming up, BS of CA somehow convinced the CA Dept. of Managed Health Care that the procedure was contractually excluded, even though it was for the purpose of preserving her fertility during treatment for a covered disease. Fuckers.
10. This time, however, the reproductive endocrinologist convinced Jess that if she was serious about her b/f, they should freeze embryos, rather than eggs, because they freeze and thaw better and the long term pregnancy rate per harvested egg is better. So they did, and I have 5 grandbabies on ice.
11. I should also say that after I explained the situation to him, the class action lawyer who took on the insurance companies in CA for making them cover reconstructive surgery - and he's won 3 of those cases so far - asked me to send him all the materials about what happened to my daughter with BS of CA. I hope my daughter ends up the named plaintiff in this one.
12. But back to her. The next step - which has been on hold for 2 years while all this nonsense went on - is to put her on Lupron again, only this time for 6 miserable months, and then operate again. Which means - another insurance fight to force BS of CA to give her a referral to Dr. N again - she has a PPO, but she should NOT have to pay out-of-network charges and a separate deductible to see a specialist that they don't have in-network.
13. So I wrote a long-ass letter for her reproductive endocrinologist to use in requesting pre-authorization for the next referral to Dr. N, who needs to see her before re-ordering the Lupron and setting up for a surgery down the road. It took forever (to me) for my daughter to take care of this - I think she's feeling a bit equivocal about the Lupron treatment while looking for a new job, which she knows will require a time-sensitive surgery and recovery. But she finally sent it in.
14. She heard from the RE today - with my letter, BS of CA approved her appointment with Dr. N without a fight! I'm flabbergasted! Let's hope the appointment doesn't have the same issues, nor the prescription for the Lupron.
15. I'm sure there will be more insurance fun along the way, but I am hoping that this second surgery will go smoothly, be definitive and her last, and she can get on with her life. And maybe try to make me some grandbabies soon, however that happens.
16. And I hope the class action attorney nails BS of CA for excluding a medically necessary surgery that was NOT merely for the purpose of delaying pregnancy, but for preserving her fertility while she undergoes these further treatments.
