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No... but the only non-cancer-related surgery since my diagnosis was dental implants. (SUPER glad I had that done when I did, since chemo interferes with the ability of the bone to heal.)

Why--what's going on (or, maybe, NOT going on)??

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My R hip replacement surgery was just denied and it makes no sense as I have severe degeneration and the same insurer paid and approved my L hip surgery back in 2015 -- Only difference is that then I did not have cancer??  My surgery is only 15 days away and desperately needed.  I've waited months and now is the perfect time with Covid numbers down.  I've already had all my pre op tests and visits all that I needed was my Covid test currently schedule for 3 days before surgery!

The denial states non medically necessary and can't improve my condition.  That's CRAZY!  I'm fighting but time is a huge issue....!   Not to mention added stress and upset.  My husband already booked time off and my family made changes to help me...

WISH me luck!!

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That's NUTS!!!  How can they say it's not necessary???  Surely your surgeon has used the required diagnosis codes, etc.   Who is your insurance company?  I just found a web page for Aetna showing all the reasons they approve or deny - betting other companies are similar and yours might have such a thing you could refer to.  

Susan 

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Lisa,

I hate insurance companies.... Tom and I wrote a blog (in this Forum) about how to fight insurance denials.  Break out the big guns and fight.   
 

@Tom Galli I seem to remember Katie telling me about a resource Lungevity hooked Linnea Olson up with a few years ago??  Lisa don’t give up hope...

Michelle
 

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It almost sounds as if they think the hip replacement is intended to be a cancer-related treatment. IOW, that the hip replacement is related to bone mets or something. I'd start with calling the insurance company and asking for an explanation. I suppose it's possible they look at your file and see all the recent cancer stuff and just assume that this is a product of that, rather than looking back at your prior history. 

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Michelle, Tom, Susan and Lexie --

 I remember when we all fought for Linnea to get her health coverage back and I plan to fight this, but it's SO annoying, because I've waiting months and now time is of the essence, not the mention I hate the all phone calls and BS I have to make to so this.  Surgery is two weeks from tomorrow, I've had ALL my pre-ops (except the Covid test which is all set).  My husband has scheduled the time off and my family is all set to step up and help.   Everything is done and ready.   I've had my surgery date for about two months now, so to find this out now, with only two week to go is ridiculous.    This was originally going to be done in the Spring, until "Covid" stopped all surgeries.   Now is the perfect time, because our Covid number are low and I feel a lot safer at this time, than I did in the Spring and do not want to wait.  I'm in misery and can barely walk, my hip buckles daily and I've been using a cane for well over a year.  I've needed this for a very long time, but put it off because I had other surgery that I needed sooner (MOHS and Reconstruction for Basal Cell, that I had done In December).   Once I had that completed and was on the mend,  I met with the Ortho Surgeon to plan for this.   

  Yes the codes are all correct, the DENIAL clearly states the procedure is a   "Total Hip Replacement" and the denial reason makes not sense.     I called the surgeon Friday and they were already aware of the denial and have set up a Peer to Peer for Tuesday, but that doesn't mean it will be approved and to be honest, NO one can seem to tell me WHY it's denied, other than to refer me to the Aetna Clinical Bulletin - http://www.aetna.com/cpb/medical/data/200_299/0287.html and there doesn't' seem to be anything in there that should be a reason for denial.  I do not have bone mets, this was caused by severe degeneration and I've had DJD and Fibromyalgia for over 20 years, it's actually the reason I was approved for SSDI back in 2006, so this is NOT a new condition for me.   It does NOT relate to the LC in any way and was pre-existing long before I was diagnosed with Lung Cancer.   I did have bone scans done to rule out mets when it first really starting to be this painful and also went back to PT for a time, but they basically said, there wasn't anything more they could do, so surgery was next.  did do bone scans to rule out mets months ago.  This shows up on all my "Pelvic" CT Scans as Severe Degenerative Changes...what more can they want or need to see.  This hip is bone on bone and even more severe then my left was when they covered that one?

  The review company (Evicore) who I also spoke to Friday,  only can refer me to the Bulletin, which is crazy, no one seems to know the "exact" reason it was denied and the reasons they are saying, make no logical sense.   I asked to be told WHY specifically it's being denied and no one will tell me?   Its' all BS!    The denial reason stated  n the letter says:  "The Type or procedure requested is not supported because research has not proven it to be helpful for your condition"???  - The plan doe snot cover serviced that are NOT medically necessary, but it gives me NO indication as to how or why they feel this in not medically necessary.  We had the exact same insurance that fully approved and paid for my left hip replacement, back in February of 2015.  Like I said, the ONLY thing different in my medical condition now is that I have since been diagnosed with Stage IV Cancer and this makes me think they are trying to deny it based on the fact that I have late stage Metastatic cancer.  Despite the fact that my cancer has been in a form of remission (Stable) for over 4 years and I have not had any treatment since August 2016.   This ALL makes absolutely NO sense but it's extremely upsetting and now I'm pissed off and have to sit all weekend before I can start making MORE calls to try and find some answers.

I asked my surgeons' office IF there is any chance this is because of my cancer DX and they said, not to their knowledge and they felt that would be unethical, I agree.

I really HATE how insurance dictates our care and what we can have done.  We've paid hefty premiums for years where we never any claims.  NOW when we need insurance, they never want to pay.

  Thanks for ALL the input -- I'll keep you all updated and ASK for all my LC friends to help me fight this, if it comes to that.  NO LC patient should be denied treatment that involves Quality of life!   

   Lisa

 

PS:  I posted this question in a few groups and did find one other patient who was denied and her insurance and surgeon told here that chemo affects the bones long term and in her cases that's why they would not pay.   I was only on chemo for 5 months and had progression, so it was very short term?  That seems like a bogus excuse too?

 

 

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Lisa,

Yes unfortunately. I have a herniation of the C-3/C-4 disk that is painful and causing numbness down my right arm and loss of strength in my thumb and right finger. I had a diagnosing MRI in February before COVID shut down our medical system. Since then, I've had telemedicine consultations with my surgeon and although some surgeries are taking place, we decided my situation is not as bad as exposing myself to COVID.

So I have kind of a joint denial. In the meantime, I have to tolerate the pain and discomfort that I know you are feeling. But, at least I can walk around without pain. My wife is starting to get upset at my dropping our china when I unload the dishwasher (weakness in right thumb) so I've had to retrain to use my left hand/arm.

In my case, this was a decision between my surgeon and I. I have Medicare and Tricare for Life as a secondary. Insurance denial was not a factor. I think I'd write the Mass insurance commission. The chemo excuse seems weak to me.

Stay the course.

Tom

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Really strange!!! Is it possible they’re saying that you didn’t have a long enough or well-documented enough period of failed conservative therapy?  Have run into that occasionally, but that wouldn’t address the ‘it wouldn’t help your condition’ comment.  OR, are they saying that because of fibromyalgia, which I know they can be pissy about.  Sounds clear that you have well documented osteoarthritis, so the dobro should be a moot point.  Sigh.  This must be horribly frustrating. Please let us know what you learn tomorrow.  If they persist in denial, I’d get an attorney involved.

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"I really HATE how insurance dictates our care and what we can have done."

Could not agree more. So sorry you are having to go through this when you need to concentrate on keeping your immune system up and being well-rested prior to surgery. I agree with all of the advice you have received here. I have only had CT scans, tele-med visits/consults and a recent thyroid ultrasound, but no hospital procedures. I hope this can be resolved for you quickly and in your favor. 

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All I know is that none of this makes sense -- I have had  Fibro and DJD for years (over 20) and have been to PT, Chiro and so on, on and off for years, but not in the last year.  I stopped last Summer when they told me it was too severe for PT to help.  They fit me with my cane and told me to consult with an Ortho Surgeon.  But, since I hated my first surgery (ended up with Stage IV cancer only 4 weeks later), I did not rush off to look to have surgery.   It was tolerable, so I just figured I could live with it.   I finally broke down and went for the consult in January 2020 and that's when we planned for the surgery.    Believe me, IF there was any way I could avoid this I would.  I hated my first hip replacement and it always felt like a jinx and I've never wanted to go though it again.  It was NOT easy, probably because I had un-diagnosed cancer at the time.   

Right now, there is no way I even want to try PT again or any more injections, to me that just wastes MORE more and time and ultimatley I'll still need surgery, so why wait?    Not to mention I do not want to be in ANY hospital unless absolutely needed because of Covid - I am already concerned about that and this worked out so that our numbers are low, so my risk right NOW is very low, IF I wait longer, we all know this winter is going to be brutal and much more risky.....

This is so upsetting and the stress is making me hurt even more...!  ARGH!   I just want to scream....

Tomorrow the fight starts all over and I'm prepared to battle, but do not have a good feeling....If they try to force me to PT, I will probably give up, Covid scares me more .... I cna handle one night in the hospital by not Pt 3 times a week.   


 

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19 hours ago, Rower Michelle said:


 

 

2 hours ago, Rower Michelle said:

Evericore denied my PET scan & initial chemo therapy treatment.  They are a third party vendor known for making shady calls.  The Peer to Peer will hopefully sort itself out.   Arrrggg!!!

   Oh NO, that is not happy news.   How in the world do they get away with this?    Now I am more concerned that this may be easy since I'm dealing with EviCore!   In the past they had denied a few of my CT Scans (non chest scans, but my Oncologist was very quick in getting them to overturn these decisions.

    Hopefully the surgical office will be as effective.   Unfortunately, I do not have a long term relationship with the Surgeon like I do with my Oncologist, so I can ONLY hope that are as stubborn and determined as I am and will make sure they have whatever data they need to quickly win this review. 

   I will fight this and make all kinds of noise about it, until they approve it, but right now, I ONLY have DAYS to get this overturned and IF they make me postpone my surgery, I will be even more upset and then will being sure that they will not forget me.  I'm also contacting my husband's Company Aetna Liason and she's helped me with past issues.   Aetna can be a real pain, but in the end, I always have won my appeals with them and they've covered everything that was in question, but it takes a lot of work and energy and I swear they make it as difficult as possible, HOPING the patient/insured will give up.   I took me almost a year to get all my Port Flush claims resolved, and I'm not about to let this go a year.

   I will also contact that State Insurance Commissioner,  if needed and have LUNGevity and the other LC Groups support me, in any way they can, especially if there is ANY sign that this is being denied because of my cancer diagnosis.     I worked in Patient Accounts for many years and used hand the "pre-certs" for surgeries - I'm quite familiar with some of these tactics and do believe in some cases, they are trying to intimidate the patients to give up, but that will NOT happen with me.  They picked the wrong person.   Unfortunately, as of now, they hold all the cards, so I'm trying to give them a chance???   

  Thanks for you input, I assume they overturned that decision for you?    Geesh!!

    LIsa

    

 

   

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My company was an international self insured organization.  I called the  HR Insurance Liaison who had the reputation of a pit bull.   The pulmonologist was able to do a peer to peer to get the PET scan approved (was denied by a CLERK) who didn’t review all the medical records.  
 

My employer demanded the triplet be authorized without a peer to peer. 
 

The biomarker studies were also denied after exhausting all the appeal options (final decision made by a doc board certified only in Internal Medicine).   Foundation One wanted me to pay & I refused (first an administrative denial for provider “failing” to pre-certify then a medical necessity denial!!).  I refused to pay the bill and never heard about it again. 
 

Ultimately my employer fired Cigna & Evicore for such bad service, evidently my experience wasn’t isolated.  

Lock and load.   
 

 

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NO news today, despite more calls, there is nothing more they will do or say until after the "Peer to Peer" review tomorrow.  At this point ALL I can do is wait to see what happens and move on from there.  

 They will either overturn the decision or stand firm on the denial, but we will have an answer tomorrow and they've told me they will call me as soon as they know.   If it's overturned, it will be approved immediately and they surgery can go on as planned on the 14th.  IF it's denied, I then have to start the paperwork for a formal appeal ith must be done in writing and will likely take weeks/months before I get any answers.    

HOPING for the best....

 

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9 hours ago, Tom Galli said:

Lisa,

Ask you oncologist to call you surgeon and advocate for you with the insurance company. A tag-team of doctors is hard to counter.

Stay the course.

Tom

 Thanks Tom -

  I will absolutely need his help if this gets denied -- I've run out of time to reach him or the surgeon today, but did talk to the surgical office again and told them if they need info from my Oncologist to let me know.   The surgeon and PA's were all in surgery today, I also left message for them to call me so I could provide them more medical history to justify this, but no one called back.  I do not think they are in the office at all on Monday.  Maybe I'll hear in the AM?  It is frustrating to not be able to talk to the Surgeon or PA prior to the review.  I've left two message, but I do not have a long term history with this office or surgeon.  I wish I did because I'd have more confidence in them.  Right now I've only been there twice.  Definitely not like the relationship I have with my Onc or my PCP.

  Hoping for the best...

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UPDATE:

   Just received the call and my surgery as now been APPROVED (as it should have been all along).   They still can't even explain why it was denied, which just goes to show how vital it is to be our own advocates.   Our medical care is vital and it's so important for us to fight for what we know is right and for the care that we deserve.

    Thank you all for your SUPPORT!    I'm so happy that I do not have to file a formal appeal and go through that long tedious process.   

       Lisa

 

PS:  Now I can focus on the surgery and recovery and finally being able to walk with a cane again.  I'm still nervous about surgery (and it's risks, but I know that this is something I could not put off any longer, without potentially causing more damage to my hip).   It won't be easy, but it'll be worth it in the end.  And happily, we have NO new COVID cases here this week, meaning the timing is very good for safe surgery.  

  

 

    

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That is AWESOME news!   If it’s any consolation, three of our four parents have been hospitalized since the pandemic (my Mom was at the peak in NJ) all of them were discharged with no issues.  Hospitals seem to have finally gotten better infection control.  As Devo would say, go forward move ahead!!”  Whip it, whip it good! 

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