My insurance company denied the pet scan needed for my melanoma surgery.

[fightforfreedom]

Our healthcare system is fucking insane. There is some good news, I hope. I believe I have figured out what the insurance company is up to. They have decided I need a head CT head scan for now. My surgeon says I need a full body pet scan. They are arguing with my life. What's crazy is, I have had many preventive scans and they were all immediately approved. Now I need a scan for life saving surgery and they deny it.

On Monday I see another surgeon who will also be involved with my surgery. She will team up with my other surgeon and also request a pet scan. Hopefully that will be enough to get them to approve it. If not I will tell my doctors I will pay for the pet scan and then fight later for a refund from the insurance company. I can't let them block my surgery.

[AngryOldDem]

1. Insurance companies only add to the anxiety.

Always looking out for their own bottom line.

They should not be allowed to play with people’s lives. Just what is health insurance supposed to be for?

Best wishes continue…

[mucifer]

2. Insurance companies are sooo evil. A lot of times they cave when doctors have peer to peer

conversations with doctors who work for the insurance companies. I believe the insurance companies hope to get more money by patients not knowing about this or their doctors not wanting to do the peer to peer because it is time consuming.

I'm so sorry you are going through this.

[BonnieJW]

20. This is absolutely true

When my sil was only 30, he developed a swollen artery in his brain. He was put into the ICU and given many scans and put on steroids. They kept him there for over 2 weeks and would not release him until the swelling went down. After one week, the insurance company wanted him out of the ICU due to cost. All the doctors refused to approve that and the insurance company backed down

[mgardener]

25. I had back surgery

The next morning I had a hospital Rep come in and tell me my insurance would not pay for that day past 11.
Still had catheter in and it was 9am.
My surgeon was standing by the door and told her I would be discharged when he decided.
I was in for 5 days.

[MFM008]

3. if you told me

it was United i would say they have done the same bull with me except not so urgent test needs.
Ive been denied MRIs and medications usually.
I hate insurance companies.

[Throck]

4. I wonder how much health care money is spent on administrative bullshit?

Administrative people and management who provide no value vs the doctors, technical, and professional people who actually provide health services. Get rid of the excess paper pushers and channel those funds into actual services.

[AngryOldDem]

11. Add hospitals into that mix.

There is one huge hospital system in my state that posts insane profits every year, most of it going to huge salaries for administrators and next to nothing for health care workers. It caught shit for that, so this year it siphoned off some of the profit to a medical school associated with it, to make it look like its profits weren’t as extreme.

They provide my health care, and I’m not impressed. The vibe is they don’t give a damn, but pay up anyway.

The whole health care system here is fucked up, if you ask me.

[tikka]

19. insurance company CEOs's salaries are in the hundred million range

Think about how much healthcare that could provide.

[BonnieJW]

22. It's spent on tv commercials

Watch TV during the evening news and Watch how many commercials there are for insurance companies and prescription drugs

[Liberal In Texas]

5. PET Scans are supposed to be very good. Insurance companies hate to pay for them.

Because they're expensive. It's good your doctor(s) got involved double-teaming the insurance company. Sometimes that's the only way to shake them loose.

Bloody insurance companies practice medicine without a license and without direct contact with the patient.

As an aside, Medicare DOES cover PET scans in most situations.

[Chuuku Davis]

6. Please name the company

[hamsterjill]

26. I second this request.

Please do.

[fightforfreedom]

43. Evicore through Cigna healthcare.

They outsource to Evicore for certifying scans. Puke! Believe me, the people of Evicore have not heard the last of me.

[TexasTowelie]

7. Make certain that you file an appeal to that decision immediately.

The insurance company might be betting that if they delay for a period of time you might not be around to need the pet scan.

[Sherman A1]

10. Absolutely

Appeal and if it is denied appeal again and again.

[Buckeyeblue]

12. Your doctor's office should be appealing for you

Sometimes it's a coding issue. Sometimes the jnsurance needs a doctor consultation.

But I agree health insurance is so fucked up.

[TexasTowelie]

18. I'm going through the appeal process with United Healthcare currently.

It is the responsibility of the patient (or guardian) to file the appeal, then the insurance company will consult with the physicians/administrative staff to determine the course of action.

I will give credit to my physician, the staff at the health clinic, and the prosthetic provider for their assistance on my appeal.

[fightforfreedom]

45. It's too time consuming for doctors to appeal, to do a peer to peer.

I need surgery now and my doctor knows this. If push comes to shove I will pay for the scan by credit card. Then I will go after Evicore and sue the shit out of them.

[spanone]

8. I hate insurance companies. You pay and pay then they pull shit like this.

[AngryOldDem]

38. I've always seen it as a pyramid scheme.

If I’m paying for it and can’t use it when I need it, WHY?

[The Jungle 1]

9. The for profit insurance system in America is foul and broken.

We demand Medicare for all!
I was so happy to get on Medicare and not have to deal with filthy healthcare insurance companies anymore.
I was jerked around for years on almost every bill submitted. It took Blue cross two years to pay for my son's birth. They do not care about us all they care about is money.
Good luck and do not give in to these crooks.

[area51]

33. +1

Insurance cos. are serial killers. No other country would put up with what we do regarding healthcare. Also I would say contact your state insurance board, and give your reps/senators hell for keeping this broken-ass system in place.

[fightforfreedom]

46. DAM RIGHT!

Medicare for all. If I had medicare the scan and surgery would have been completed already. That's a fact.

[The Jungle 1]

48. It is important for you to continue to spread your story.

Healthcare insurance companies hate when people tell the truth about them.
Post this crime every where.
The one thing I noticed the last few years I was in private insurance. They put on a very strong act to help you. Bad press was killing them.

[Rustynaerduwell]

13. This is why I wanted to scream every time I heard someone say

"I don't want the government get in between me and my doctor".

[Botany]

14. Get a lawyer and go after the insurance company. Offer to give that company millions of dollars ...

... of bad P.R.. And get the PET scan ASAP. Good luck.

[TNNurse]

15. I will always remember when the "caseworker"

for my insurance company called and told me "she" was the one who OK'd my mastectomy. Like there was any question it was necessary. I did not scream. I could not say a word that would not have been a problem for me in the long run.

I suspect if the cost of the pet scan becomes a problem for you, I and some other folks on here could help out.

Please do not delay, melanoma is scary.

[Traildogbob]

16. Somebody in

Media please ask trump or any GQP, where is a full written explanation of the greatest, most beautiful cheap health insurance, the likes no none has ever seen, in two weeks, every two weeks after January 2016. Precisely, the likes “no one has ever seen”, especially any GQP.

[Lonestarblue]

17. The goals of insurance companies are totally different from healthcare goals.

Their goals are to make as much profit as possible, and if they’re able to deny healthcare they will. With major illnesses like cancer, that have policies forcing patients to try the least expensive treatments first, even when their doctors know those treatments aren’t as effective. How many people die before they even get to the more expensive treatments the insurance companies refuse to pay for? Our healthcare system truly is a disgrace,

[highplainsdem]

21. I'm so sorry you've had to go through this. It is insane.

[multigraincracker]

23. When I just had private insurance

they always denied everything until the doc called. After I went on MC that never happened. My private insurance that pays a smaller portion, now has to go along with MC.
Back then, my doctor said the insurance person with a high school degree is supposed to tell him what is medically necessary.

Best of luck and I’m sure you will get the test. Just have to jump through hoops first.

[JT45242]

24. Fight with letters of medical necessity

There are several insurance companies who basically deny everything expensive at first hoping that people will give up.

If you fight with letters of medical necessity from two separate doctors. They will often cave. Sometimes they will make you go to one of their picked guys to add an additional hoop to validate the other statements.

Happens all the time. Keep up the good fight.

We are rooting for you

[Martin68]

27. I am so sorry to hear that your insurance company thinks they are entitled to practice medicine.

I think your doctors have the right idea in applying pressure and not giving up.

[alphafemale]

28. Ask your doctor to do a peer to peer

Often the fastest way to get an appeal overturned.

edit - I mean a denial.

[ck4829]

29. This is ridiculous. This is oppression. We need to stop being OK with this.

Last week, my mother got a 4000 dollar bill because, literally, a procedure was not covered because she didn't get a test to OK another test before the procedure could be done.

[Stainless]

30. Ask for the credentials of the people denying your claim.......

Insurance companies hire people who receive low pay and little training and are basically there to deny your claim. If your claim is denied then you have a right to ask for a review and to see the credentials of the person who denied it. Most will cave and approve your claim! It's worth a try.

Medical Insurance exists to come between you and your Doctor and to deny your claim in order to maximize profits. The person reviewing your claim must be medically certified and many of them are not.

[Ilsa]

31. My former insurance company almost made me suicidal

with their coverage denials.

I wish you only the best and good luck.

[MissMillie]

32. This is why I am against health "insurance"

A health "insurance" company's job is to make money, even if it means denying care.

Universal health care for all.

[Wicked Blue]

34. Call your state's insurance regulator right away and raise hell

Your insurance will try to stall this any way they can.

Speed is extremely important.

I had a friend years ago who had a black spot on her cheek. She had Medicare. They stalled and stalled. When she finally got the surgery, they had to remove about 1/3 of her face and an eye.

[flying_wahini]

35. Is there an Insurance Board in your state you can appeal to?

[Evolve Dammit]

36. "Health care" What a misnomer. They are in the business to deny and weasel out of coverage.

And every year it gets worse. I share your outrage.

[MontanaMama]

37. Please consider filing a complaint with your state

insurance commissioner. Most states have the form online that you can either submit electronically or you can print it and mail it in. I was an insurance biller for a medical practice for 21 years. I filed many of these complaints on behalf of my patients and I have filed at least a half a dozen of them for members of my own family.

It is not common knowledge that consumer advocacy groups such as Consumer Reports, AARP, etc. will make recommendations about insurance companies or not based on these types of complaints. Insurance companies will do about anything to clear them up… They usually will come back with something like “sorry for the misunderstanding, we will cover the recommended procedure by your doctor“. I have never had one denied… They are not complicated or difficult to do.

Insurance companies never have your best interest in mind. Ever. Their only obligation is to their shareholders. Never forget that.

[Karma13612]

39. Of course it needs to be a full body scan!

The insurance company just wants to make sure of no brain mets. That is ridiculous! You need to look for mets in bones, and other organs.

My husband had malignant melanoma. The docs explained that the melanoma on the skin grows very slowly. But, when it mets to internal organs, it grows extremely fast.

Flippin’ insurance company should be charged with attempted murder.

Universal care, now, cradle to grave. Get rid of insurance and make it a payroll tax. It was evil when I was working and paid the EXACT SAME insurance premiums as the CEO of my employer. I was making $15 per hour and he was making $500K a year. GMAFB. And when I asked HR about it, they said you can’t prorate the premium based on salary because insurance premiums are considered a ‘product’. The same way as buying a loaf of bread.

That was not a good day for me.

[CrispyQ]

41. I remember when there was one plan for the entire company.

But the execs didn't like that cuz they wanted better plans for themselves, but didn't want to pay for the better plans for the employees. Now most companies offer 2-3 different levels of coverage, so the $15/hour workers can get a bronze package & the execs can get a gold package.

Those at the top are always taken care of. Same as it ever was.

[Karma13612]

49. Same as it ever was.

At our hospital, union employees negotiated for specific plans and rates. The non-union had different plans and rates and options. So, pretty much what you just said. And the RN’s had very special plans thru their unions as well. And I remember our PTO time was severely cut back while the RN’s negotiated for their PTO cut-back to begin years down the line. We were feeling the pinch long before they did.

Anyway, I’m retired now. Things like PTO, insurance rates, and DST are all in the past for me. Happily. Although it would be nice if we could get better rates with MCR and negotiated drug prices. But, here we are.

[CrispyQ]

40. Because in American

insurance company executives have more say about your healthcare than your doctors.

A friend was in a car accident & needs a scan but her insurance company wouldn't pay for it. In the interim, she lost her job & is now on Medicaid, & they won't pay for it either. She offered to pay for it herself, but because she's on Medicaid, she's not allowed to. I guess they figure if you can afford to pay for your own scan you shouldn't be on Medicaid. She & her boyfriend are going to Mexico next month & she's going to get one there.

People with healthcare issues shouldn't have the additional stress of worrying about how they'll receive or pay for their treatment.

There are good suggestions in this thread. Good luck.

[iambotchan]

42. Insurance Companies... SMH

First I should start with the fact that I absolutely despise the US healthcare insurance system. It is clearly a system of greed and privilege where we all walk around with giant dollar signs tattooed on our foreheads. I started a new account (I have been reading through DU for a long time - Since George W, but rarely commented and don't have the email associated with my old account any longer). I came out of stalker-ville for this reply.

I have been going through a similar path with PET as I have been diagnosed with Stage IV colorectal cancer with liver metastasis. I'm young for this diagnosis and was angered that the PET scan was denied 2x as well. I have worked with my local and a national cancer research hospital (very well respected, especially in my area of cancer). The problem with PET and the reason they deny in the US is that if you already have metastasis the original tumor (which is the source of spread) needs to be addressed (where applicable) and in many cases chemo will be warranted to remove all cancer. Due to the fact that PET will only show established tumors (about the size of a grown adult's pinky nail) the assumption is that test is not warranted until after primary tumor removal/post aggressive chemo. This is especially true where there is already known metastasis and they have identified the primary tumor(s).

With that said, addressing through your state will be the best course of action especially if your doctors are adamant of it's necessity. However, don't let it delay any treatment.

This post hit home with me and I wish you all the best in your battle with your cancer. I just started my first round of chemo (chest port FolFox 5-FU over 6 months).

All the blessings and positivity I can send will be directed your way.

[gopiscrap]

54. welcome to DU

[JMCKUSICK]

44. Ask Dr to present case to medical review board

My insurance denied my 1st back surgery, and my Dr. went to the board, made up of doctors and justified the need and got the denial overturned in less than a week.

[fightforfreedom]

47. Thanks everyone for the support.

I have a feeling my Melanoma, which never showed itself, it was found by chance, may be the end of me. Just a gut feeling, of course I have not told my wife what I fear. I hope I am wrong, but every day that passes without a scan or surgery is a death sentence.

It's strange, I do not fear death. For the past few weeks all I have thought about is how I am going to take care of wife before I die. She is my whole world, I have to make sure she is OK if I get bad news. I have been making plans, writing them down so she will be taken care of. She will know what to do if I pass.

[Karma13612]

50. You are a good husband.

Your wife will feel your virtual hug of caring, as time goes by. Do the best you can while you have the time with her. I hope the news is not as bad as you are anticipating.

[Eliot Rosewater]

51. Allowing a FOR PROFIT corp to decide if you get healthcare, heat, water, access to internet, etc

is madness.

[iemanja]

52. You can fight it

and hopefully make them pay. You might do the other procedure first, just to pacify them.

[Ron Green]

53. One risk pool is a health care system. Multiple risk pools is an investment scheme.

We have enough investment schemes in this country; we need a health care system.

I’m sorry you’re having to go through this. I wish you health AND lucky breaks.