July 12, 2010

Not Medically Necessary and Other Nonsense

On Thursday, I got a call from the surgery center where I'll be having surgery next week. They told me what my co-pay would be and everything seemed to be good to go.

On Friday, things changed.

It took one call from my doctor to reduce to me to a crazy lady who didn't know if she wanted to scream, cry, hit someone, crawl into a dark hole, or all of the above.

My insurance denied the surgery claim.

The plan for next week is that the plastic surgeon is going to open me up, remove the screw in my tibia, clean up the mess that is inside my leg, attach a piece of alloderm (commonly used for breast reconstruction surgery to attach implants to actual human tissue), cut out the nasty scar I have now, and close me up from the inside out.

The insurance has said this is "not medically necessary" and that alloderm is only approved for use in the "breast." They're also saying this surgery is "experimental," to which I'd like to say "Of course it is, you morons, because how many people have the 'common' problem of having a screw back out of their bone, complicated by the fact that they have no tissue in that area which means that the skin is basically indented and transparent. Oh, and it bruises and bleeds a lot. The screw also cuts me from the inside out if I happen to graze it on anything, even lightly."

So, in the world of medicine, where it takes almost two months to get a surgery scheduled and even longer to get an actual physician to call you back, I need two letters of medical necessity from a plastic surgeon and my orthopedic surgeon, by like Tuesday (as in tomorrow). As if that's going to happen.

To say that I am frustrated would be an understatement of universal proportions.

Because I knew I wasn't going to be able to handle speaking to anyone about anything regarding this, Mr. BBM took over and called the insurance company and my plastic surgeon's office.I tackled the office of my ortho guy and the lady on the other end of the phone from me made the mistake of saying "Humph, well I can't guarantee that he can have a letter for you." Yeah, because it's SO hard for a physician to dictate a letter and have someone type and fax it.

She was about ready to hang up the phone, when I reiterated that my ortho guy said he would do whatever I needed him to do so I can get this taken care of and that he, himself, had offered to write a letter for me. I told her that I didn't wait until the last minute to ask him. The insurance waited until the last minute to deny the claim, not even two weeks before surgery. This isn't my fault and I clearly need some help. She repeated her line and I had an internal debate about whether or not me telling her off would expedite the process or not. Instead, I opted to tell her that the screw is soon going to come out of my leg on its own if it's not fixed. I also gave her the visual of it cutting me from the inside out. I'm hoping that will motivate her to be a bit more helpful. My gut tells me it won't.

In the medical profession, people are just so used to saying the word "no" that it seems they say it without even considering the desperate person on the other end of the phone. Mr. BBM tells me I am having this surgery whether it's approved or not, and that we'll spend our lifetimes fighting the charges if necessary. I just wish something about this whole knee business would be easy, just once.