Ablation Denied!

[redpine]

Hello all,

Anyone have experience with their insurance company denying their ablation? I would be interested to hear about this from others who have run up against the same situation, and how they responded?

Literally days before my scheduled ablation, my insurance company (Regence) sent me a pre-authorization request in the mail. I immediately notified my EP who was surprised to hear about this given that they had already sent Regence all the necessary medical documents, etc. They again submitted the necessary medical documents on my behalf and a week later, I got a letter denying my request, citing that my drug therapy (I'm on 200 mg of Amiodarone and Pradaxa) was sufficient to handle my AF.

Prior to getting on Amiodarone, I have had infrequent AF episodes over the last 12 years (they began while running). All of them resolved spontaneously with 12-18 hours, except the last one which went on for days and required cardioversion.

My symptoms on Amiodarone involve neuropathy (numbness), excessive heat, and pins and needles in my feet, facial heat (most notable at night), and insomnia (I am only averaging 4-6 hour of sleep a night which is having a big impact on my work).

My added concern is the longterm use of Amiodarone given it's toxicity, especially on the liver. As I also suffer from hemochromatosis, any added toxicity on the liver increases the potential for irreversible liver damage such as cirrhosis.

I am rather amazed that my insurance company will not approve this procedure; on the otherhand, I can also see that this could ostensibly be about not wanting to pay out $16-20,000 for the procedure.

MY EP's NP confided in me that they have previously had trouble getting this procedure approved by this insurance company for some patients, even for those who are far worse off than me.

[R1100S1]

No

But once our healthcare is under control of the American Private Health Industry probably yes

[Dodie117]

Most on here are UK resident and almost all use the nhs - free to all. It has its problems but is a godsend in comparison to most healthcare systems. There are some Americans on here (look up SRMGrandma in members). Sorry we have not been more helpful.

[redpine in reply to Dodie117]

I knew we had quite a few posters from the UK here, but I did not know that the majority posting were UK residents. Thanks for clueing me in.

[Buffafly]

Perhaps your EP could explain that the Amiodarone is only a short term medication to aid the success of the ablation and that if you continue to take it you will probably incur much greater expenses down the line! The same goes for stopping it because then you will definitely need an ablation.

[redpine in reply to Buffafly]

Thank you, Buffafly. Excellent advice!

[Amcech]

I had to fail 3 rhythm control medications before they would approve my first, I'm in the U.S. Recently my echocardiogram was denied because I'm in NSR with medications though my echo last year showed borderline chf and we have no way to check improvements without the echo. Insurance companies just don't care. And it has nothing to do with "Obamacare " it's been this way for years!

[redpine in reply to Amcech]

Thank you, Amcech, for replying. I mean, really, they won't even pay for an echocardiogram? I think that one of our biggest problems in the US is the insurance companies who are often the ones to deny coverage even when the doctor believes the procedure is warranted and needed.

I think until we manage to get rid of this "middleman" we will continue to experience ever-rising healthcare costs as well as such nefarious policies as non-insurance of pre-existing conditions. Of course, the problem is the insurance lobby and politicians who get huge sums from them. It's a totally rotten and corrupt system that is just plain broken.

Just the word "single-payer" brings screams and hysteria of socialism from conservatives and Republicans. Much of the American people are just plain ignorant about socialism, many not even aware that we already have it with Social Security and Medicare.

Anyway, excuse the rant. You might surmise I hold passionate views on this topic. :0)

[Amcech in reply to redpine]

No worries! I have very strong views, very similar to yours, too! If I wasn't feeling so well I would have paid for the echo and then fought the insurance company but right now I don't need the stress!

[CaroleF in reply to redpine]

I know this is not the place to discuss anything directly political, but I can't tell you how good it is to hear an American saying that most of their country's population don't know or understand what socialism really is. I'm in the UK and British; I find myself screaming at the TV whenever anyone (American or otherwise) suggests that any policy in the slightest degree to the left of centre-right is 'socialism'. That notion even seems to creeping in here in the UK where 'the man in the street' ought to know better!

[Probably best not to continue this conversation ;-)]

Other than that minor rant, I am so very sorry to hear of the problems the OP faces over his insurer's stand point.

[redpine in reply to CaroleF]

Anything socialistic runs completely counter to the conservative worldview, the predominant theme of which is the felt experience of having power, seeing it threatened, and trying to win it back.

Thank you for your empathy!

[jeanjeannie50]

Amcech and other posters to the forum. If you ever read through your post after it's on this forum and discover that you've made a mistake (I do this all the time) you can edit it. Click on More underneath your post and scroll down to Edit and then make your changes. Click on Edit response and the change is done. You will see that you can also delete a post this way.

Jean

[Amcech in reply to jeanjeannie50]

Thanks!

[Hidden]

Hi redpine,

Sorry to hear about this situation. I'm American and have had to battle insurance companies myself. I still regularly take them on. My insurer didn't deny my ablation 5 years ago, but then they refused to pay for it or any of my care afterwards - to the tune of almost $150,000.

I still have the framed bill for the ablation and night in the hospital - $104,000 - and the note they include: "Please pay in full at your earliest convenience."😂

The good news is that I fought and won. Took me around 1.5 yrs and involved much kicking of ass, but in the end I got more paid for than if they'd just followed the benefits in my contract. They had played the "pre-existing condition" game, but I proved them wrong. I happened to get diagnosed 6 months before the Affordable Care Act made it illegal for them to deny coverage based on a claim of pre-existing condition.

[Side note to forum pals in the UK: if ever you are frustrated by the NHS, consider this pre-existing condition nonsense we have to deal with over here and be grateful you don't have to deal with it. It was a battle to enact the law that makes it illegal for insurers to deny coverage based on pre-existing condition. Many of the post-Obama leaders have been fighting hard to strip this away - when half the country now has a pre-existing condition.]

I recommend that you (and any of the Americans here at the forum who encounter insurance challenges) contact Mary Covington, of fixmyclaim.com. Mary is the head of this company (Denials Management) and is a Health Care Advocate. That's sort of like being a lawyer (but isn't), but within the crazy, complicated world of health care, billing, insurance, etc.

She takes on the insurance companies on behalf of the little guy and regularly wins. She's been at this for over 40 years, knows all the procedures to follow and also knows the games the insurers play so that they don't have to pay. Some of the more disreputable ones actually count on patients to be too sick, tired, ignorant and vulnerable to fight them.

She guided me as I appealed my denied claims and coached me throughout my battles. I don't know if she also works with situations like yours specifically, but it would definitely be worth contacting her office to ask for advice. She is a wonderful, kind, compassionate, speak-truth-to-power woman and I'm still in touch with her.

The major bit of advice I give to people with insurance challenges is to keep close track of what the insurers say and do and call them on every single mistake. They regularly make loads of them and there are mechanisms to get them to stay on top of things. I think that most Americans don't realize that bills aren't written in stone and a lot is negotiable.

I held my insurer to what I'd had them put in writing before I committed to my 2nd ablation and kept insisting they honor it and ended up saving over $5000.

Best wishes to you.

[redpine in reply to Hidden]

Hi Nella,

I missed your post! Thank you for your advice! Maybe I should contact Mary Covington. How much did she charge you?

Thanks for posting!

[Hidden in reply to redpine]

I would definitely recommend contacting her. She bills by the hour; don’t remember exactly, but it was reasonable, like between maybe $1000-$2000 total over 1.5 yrs or so, which saved me from bankruptcy. Plus, it was education and training that has saved me thousands more ever since.

I happened to be in my pharmacy one day after being hit with bills & had started to research Health Care Advocates. A lady happened to wander in, I chatted with her, told her about this and she recommended Mary. I always follow up on that kind of advice. It saved me. I’m passing it on to you. 😊