Health insurance issue

[claudia]

OMG - I just got a letter from United healthcare saying my surgery is not "medically necessary"!
then it goes on to say that my health insurance doesn't cover inpatient hip surgery anyway!  What???  I've got the best pan that United offers.  It's a PPO
I've had two arthroscopic surgeries on that hip and two otho's have said there is nothing left to do but a hip replacement.  Are they kidding?  I am in 24 hour pain and my life is significantly impacted and they say it isn't medically necessary? 
Is this usual BS from the insurance company?
What do I need to do?

[kimberly52]

File a formal appeal.

Good luck,

Kim

[podgornymd]

Dont know the answer to that but i would get with your orthopedist and see if they can help you . Their group should have someone devoted to dealing with this to help patients.

[Marco Polo]

Claudia:  I agree with the recommendation to get an orthopedic surgeon to confirm you need a hip replacement.  Hip Resurfacing is performed using the same treatment code.  Also, some companies have a patient advocate service that assists covered dependents with appeals when coverage is denied.

[kimberly52]

http://www.patientadvocate.org/resources.php?p=36

http://www.uhc.com/united_for_reform_resource_center/health_reform_provisions/appeals.htm

[hernanu]

Claudia, I had both hips resurfaced and paid for by United Health Care.

I'd work with your surgeon and get in touch with them. They had no problem paying for mine, I did have to prove it was medically necessary, but all it was then was to have a form sent by the surgeon.

I'd challenge it.

[Tin Soldier]

Wow, that's crazy.  I've heard of making you pay a little extra, like $500 because "it isn't a proven technology" or some crap like that, but to not cover any hip surgery?  That seems way off course.  I like everyone'es ideas.  I think the surgeon's office may be the best place to start.  Good Luck.

[claudia]

Hello everyone,
Thank you for your help.  Thought I would update you.  Yes, United said the surgery isn't necessary but I believe that will not be problematic issue as I have 3 specialists on record that state it is my only option.  The real issue right now is that I found out my former company (I am on COBRA) excluded an "inpatient" option for hip surgery to save on premium costs.  So I am dealing with an exclusion that was due to the contract my company made with United.  Unfortunately, I have already been told by Dr. gross's office that outpatient surgery is not an option for me.  The people who work with insurance at Dr. Gross's office are working diligently to appeal this.  Since this is my only option.  If they can't -then I guess I am pretty well screwed as whether hip resurfacing or replacement, no one will do this as outpatient on me. 
It hasn't been a good week for me on some other of "life's issues" so there isn't a lot of fight in me.  The last thing I have energy for is fighting with an insurance company.  Worst case scenario, I would have to wait. 
We will see what happens and I will let you know.
thanks

[podgornymd]

I am sorry you have to deal with this being in so much pain. I have never heard about an exclusion clause like that. I dont have a great answer for you but dont give up yet. Hopefully Dr.Gross' office can get this done. Good luck and hang in there.