sex, lies, and uterine fibroids

The number one question that's asked over and over again regarding medical insurance, is NOT how to find the best insurance plan or provider, but rather:

Denial for treatments requiring pre-authorization is occurring on a scale that can only be described as phenomenal. Oddly enough, however, hysterectomies are fairly easy to get authorized...it's the myomectomies and embolizations that seem to be under the tightest scrutiny. In fact, any procedure offered that doesn't result in a "definitive" outcome for the treatment of uterine fibroids is tagged as being less than desirable by insurance providers. Regardless of the work/man-hours lost due to the recovery period of a hysterectomy (6-8 weeks). Regardless of the known post-hysterectomy complications that might result in additional, long-term care. Regardless of the woman's desire to keep her uterus.

Are all hysterectomies automatically approved? No. They're not. Insurance providers require proof of the necessity of a procedure first -- but some of them actually review the documentation submitted and deny cases they determine to be unnecessary or insufficient in information to make a decision. These denials are rare, but do occur. Most often, however, are the letters of denial and phone conversations regarding a denial that direct a woman to CHOOSE hysterectomy instead of the treatment option they are requesting. Document all conversations you have with representatives of your insurance provider. Although it is hoped that the information detailed below will help you overturn a denial for treatment, if you are unsuccessful and wish to pursue the matter legally, good documentation of all communication with your insurance provider may be extremely helpful to your case.

If you are currently looking at a denial letter and believe your case should have been approved, then the following information may help you successfully appeal your case.

1.	Write a personal plea detailing your health history as it relates to your current condition. Make the letter as brief as possible (no rambling), but include the following:
		Explain why you want and need the procedure you've requested. How are your symptoms impacting your Quality of Life?
		Explain why each and every other treatment option is an inappropriate choice for you. For instance, if you are attempting to get uterine artery embolization approved, specifically state why "watchful waiting," medical therapy" (progestin/oral contraceptives), myomectomy, hysterectomy, endometrial ablation, etc., are not valid approaches to your situation.
		Identify what you have done, over time, to try to live with or resolve your health symptoms from fibroids.
2.	If your symptoms include abnormal bleeding, the following are a few of the items that reviewers look for:
		Have you tried medical therapy (oral contraceptives/progestin) in an attempt to regulate your menstrual cycle/bleeding? If so, what was the outcome?
		Have you undergone an endometrial biopsy to rule out hyperplasia or endometrial cancer?
		Are you anemic? If so, have you been treated with iron? What were the results? NOTE: Occasionally a woman will tell me that her blood tests do not show that she is anemic while at the same time telling me she passes blood clots during her period and that she's tired all of the time. In following up with a few questions, it's almost always the case that blood tests were done in her gynecologist's office when she wasn't on her period. Exams are typically scheduled only when she's NOT bleeding. A blood test administered during the peak of her passing blood clots each month might present her with different results showing anemia...
		Have you had a transvaginal ultrasound and/or MRI within the last six months?
		What is the size and location of your fibroids?
		NOTE: Size and location are critical factors that should be playing a role in your choice of treatment. For example, if your fibroids are submucosal and you are seeking UAE, would hysteroscopic resection of the fibroid be a better option? If not, why not? If your fibroids are subserosal and you are seeking UAE, would laparoscopic myomectomy be a better option? If not, why not? Consider all of the potential treatment options and determine viability, risk, outcome, etc., and present a logical justification for your treatment choice.
3.	Ask your gynecologist to write a supportive letter verifying the details of your letter and detailing your current medical condition, what therapies have been tried, what failed, and what his/her professional opinion is regarding the need for the treatment desired. This is a critical piece of your appeal and cannot/should not be overlooked no matter which treatment option you desire.
4.	If you are seeking approval for UAE, ask your interventional radiologist to write a supportive letter verifying your need for the procedure and anticipated outcome. Because this procedure is not well known, it may be important for the IR to include additional information that technically details the procedure and identifies known outcome from current studies. Include copies of published medical reports and/or a detailed bibliography of peer-reviewed documentation that can provide additional information about the procedure and its anticipated patient outcome.
5.	Before mailing, photocopy everything in the packet. Keep one set for your own file and then make any number of additional copies for legislative representatives of your choice, the insurance regulatory body that oversees insurance providers within your state, etc. Mail within the time frame allocated to you for an appeal (this varies by state law and by provider) and send it certified with return receipt.
			NOTE: If this is your FINAL appeal option, you may want to seek legal representation to guide you through this process. Although not entirely necessary, establishing a relationship with an attorney in your final phase of appeal can help you to move forward much quicker with civil litigation should you, once again, receive denied coverage for treatment. For more information and basic hints on how to find an attorney, check out the Patients Rights website.
6.	If you consider the denial you received unjustified and communication from your insurance provider entirely inappropriate, you may want to consider the involvement of your legislative representatives. Names, addresses and phone numbers for all current legislative representatives are available online at the Patient Advocacy website. Once you identify who you want to involve in your case, contact them via telephone and ask specifically for the name of the person handling health insurance/HMO issues within the representative's office for your state. Get their name, telephone number and/or email address and call/contact them personally, if possible. At a minimum, direct all correspondence to your chosen representative with an ATTENTION: to the person you've identified as handling health issues.
			NOTE: In order to act on your behalf, all correspondence to legislative representatives requesting action/involvement on their part regarding your personal health issues must include a letter authorizing them to access your medical records and speak for you.
7.	Finally, it may also be appropriate to submit your appeal, along with a letter of explanation and a formal complaint, to the medical insurance regulatory body for your state. A complete list of contact information for each state is available here. While state insurance regulatory bodies cannot FORCE your insurance provider to approve your treatment choice, they can have an impact.

Link	Site Name/Author	What You'll Find
www.patientadvocacy.org/	The Center for Patient Advocacy 1350 Beverly Road, Suite 108 McLean, VA 22101	The Center for Patient Advocacy is a grassroots coalition working to ensure that patients have timely access to the highest quality health care in the world. The Center advocates for the rights of patients on a national level. This site contains a complete listing of state insurance commissions as well as contact information for all legislative representatives.
www.hmopage.org/	Physicians Who Care	Developing an understanding of and fighting back against HMOs.
www.medconsumer.com/	American Medical Consumers	Health care has become negotiated care. AMC helps Medical Consumers with the negotiations.
wellnessweb.com/INSURANCE/ health_insurance_index.htm	Wellness Web	Choosing and Using a Health Plan. Comprehensive information on how to choose a health plan and understand the policies that guide that plan and your coverage.
www.public.asu.edu/~nancylee/ UAE/UAEHMO.html	Nancy Lee member of "Embo" email list group	Series of letters and appeals to Ms. Lee's insurance provider in her quest to get UAE covered after an initial denial.
www.ohsu.edu/dotter- fibroid/FE_phres_frame.html	Dr. Robert Andrews, Interventional Radiologist Oregon Health Sciences University Dotter Institute	UFE related insurance information available for those needing assistance with the appeals process. Includes a bibliography of written materials to date, communications from conferences, list of insurance providers that have covered UFE to date, etc. Your computer must have Adobe Acrobat to read this file. Look for the following link on this page and click on it: "Alternatively, this information can be downloaded as a .PDF file by clicking here."