Thursday, September 10, 2009


I wish I was posting with some miraculous news that the insurance request had been submitted and we had already heard back and they approved the surgery with no questions asked. But alas, we know better than to think that was possible. So here is the update so far.

1. I have emailed and left a message with UCI guy about him submitting the request for the surgery out-of-network. He was on vacation until this week, so I have an appointment with him next Friday, September 18. I'm assuming at this appt we will discuss the referral and then he will submit it after that.

2. I have asked SD doctor to write a letter on my behalf stating why the k-pouch is right for me vs. a traditional ileostomy. He has said he will do this and will send it to UCI guy along with a pamphlet about the k-pouch so that UCI guy can submit this as additional support with his letter and referral.

3. Even though we decided to pay out of pocket for the consultation with SD doctor, the appeal process to having it approved was still going on with my insurance, it had been sent to a third party -- The Managed Health Care Department -- for a review. I received a very dissapointing letter from this third party. It stated that they also agreed with our crappy HMO to uphold the denial of the consult. They stated that there were amazingly another two highly respected colo-rectal surgeons available within network that were available for consultations and did k-pouches.

Well even though I knew of both surgeons listed, I also knew they didn't do k-pouches, but I called both offices just to confirm and I was of course right. So armed with this information, I called my HMO to challenge the fact that they've given me 5 surgeon's names who they claim do k-pouches when in fact none of them perform that procedure. After hours on the phone talking to a manager and having her making calls of her own. She had to call me back and explain that what they really meant by giving me all the surgeons names was that they could all preform the traditional ileostomy and since that is an option for me that they wouldn't approve me electing to have the k-pouch.

Although I challenged this by saying I'm not electing surgery, but since I have to have surgery, I should be able to choose between the two options that are available in this situation, even though nobody in-network performs the second option. But alas, they stuck to their guns.

As you can imagine this is extremely frustrating and scary. We are still hoping, beyond hope that UCI guy's referral, with the back up from SD doctor will get through. After all, both of these doctors said in our appts that the insurance would have to approve this since nobody in-network performs the k-pouch. I hope they are right, sometimes even though the doctors believe something should be true, the insurance still fights, as is evident with the referral for just the consultation.

So where does that leave us now. Realistically UCI guy probably won't submit the referral request until the week of Sept 21. Which means, that at best we won't hear anything until the first weeks in October. And I have to wait for approval to even schedule my surgery. GRRRR.

There are many reasons this is frustrating; one, I just want to get on with this get this done and start recovering; two, even though we are switching to the PPO in January and I could just have the surgery then, I really can't imagine living another four months the way I have been the last two months -- horrible pain, partial obstruction (my GI said I just would have to live with this until my surgery. There is nothing they can do for me before then), pouchitis and a nasty cough.

** So with all that said, dear blog readers we are sending out an S.O.S. (is anyone else thinking of that Police song right now? I digress) If any of you know of a health care lawyer or someone who works in the health care industry that can provide us with guidance on how to deal with the insurance if they do deny this next request, please email, call or leave a comment here on the blog. We want to be ready to jump into action ASAP, if/when that happens. **

At this point I've done all the coordinating I can do, I now just have to wait for my appt next week and see what happens. I know that may sound ridiculous to all of you, but that's how the process works, so please don't ask why UCI guy can't do anything before then. I don't have the answer to that, as I've said, they have all the info but sometimes the process is just the process and I truly believe he's the guy that has to spearhead this in order to get the best results.

Thank you in advance for any information you can pass on. And thanks for continuing to pray and send good thoughts our way for some resolution to all of this in the very near future.

1 comment:

Al said...
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