Any sugg. dealing w/ Ins coverage - infertility vs. MA (sorry so long)

October 28, 2005

Ladies,

I could use some suggestions from anyone who has had to go rounds

with insurance coverage. To date all of my appts have been coded as

Infertility (which is only covered at 50%) because that was my

original intent when I first saw the RE. But as a result of my 1st

test, HSG, the RE found my T-shape and a blockage in my tubes. We

immediately schedule the lap/hyst and I started to ask a few

questions about coverage. At this time I knew absolutely NOTHING

about MAs as no one in my family had ever been dx.

I started by talking with the billing clerk at the RE office who

stated that any procedure re: blocked fallopian tubes " must " be

billed as IF but the T-shape would be coded separately. I then

proceeded to get the all of the codes related to the surgery and

called the claims dept of my ins co to get the assoc costs. After

speaking w/ at least 4 sep. pp, I was told that everything would be

covered at 50% because it was all related to IF. I kind of gave up

at this point and figured that it needed to be done and it would be

worth any cost.

FF to this week and some prompting from Ann & Mikell (thanks

ladies!!!), I've gotten fired up again and I am preparing to fight.

I got a copy of our ins. Cert of Coverage from my HR Director (I

live in MI and have MCARE HMO). She mentioned that since all claims

are processed based on the procedure and diagnosis codes that it

might be a good idea to talk with the billing clerk in my dr.

office. So I called my docs office and she stated, again, that that

lap would require the infertility dx code because it was to correct

the fallopian tube.

This is where I'm getting a little confused as to how to prepare an

appeals argument. I believe that I can argue the hyst portion of

the surgery easily enough as I've found several published medical

studies detailing MAs. But, based on what the billing clerk stated,

the lap part is a little trickier. The RE explained that he found

that the end of my fallopian tube, near the fimbriae, was semi-

closed so there was a greater risk that an egg wouldn't be picked

up. He found no sign of endometriosis. To me, it's obvious that

this problem wouldn't be the result of some sort of trauma to the

region, but that it's been there since birth. But since every MA

document that I've found only focuses on the uterus, how do I gather

evidence to support that the lap was necessary in regards to dx and

treating the MA?

I'm going to start by going to my RE directly but I would greatly

appreciate any suggestions.

Thanks in advance,

T-shape remodeled 10/06/2005

TTC #1 since 01/2003

October 28, 2005

, I live in Michigan too and have Blue Care Network (also an HMO). Now

my insurance is a bit different as it does confer infertility excluding IVF.

However, my lap/hyst was not diagnosed as IF, it was diagnosed as a birth defect

and I paid zero out of pocket costs. Don't know if this helps or not, but

thought I would share. And BTW, my RE's office handled all the referrals, etc.

So I would definitely go to them first. I actually got to know the biller quite

well. LOL

Diane

PCOS, SU Resected

DD 5/25/2005

---------------------------------

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October 28, 2005

,

Insurance can be terribly frustrating, can't it? I've spent at least 40 hours

this year trying to resolve claim issues between doctors offices and insurance

companies. What I have found is that billing clerks really don't always know

what they are talking about. I have almost never had a problem with the

insurance company. The coverage may not be what I want, but payment errors have

almost always been the billing clerk's fault in my experience.

Having said that, it sounds like both your insurance company and your RE's

office may not be handling your claims correctly. It sounds like you have

really worked hard to get somewhere with your insurance company. Did you find

out what the coverage is for correcting birth defects? While they say that it

is IF, diagnosing & correcting a t-shape is not necessarily just IF. It can

cause pain and you could have other problems that can only be diagnosed via

hysteroscopy (such as intrauterine adhesions or scarring).

As for the lap, it is the same thing. It is a diagnostic procedure for issues

that may or may not be fertility related. Do you have any other risks

associated with the fallopian tube? Is there an increased risk for ectopic

pregnancy? Is your risk of infection increased due to the partial blockage?

I'm not so familiar with this issue, but these may be questions you can ask your

doctor to help build your case that this is not just an IF issue. Also,

endometriosis is not just an IF issue either. Even if your doctor did not find

any, that doesn't mean that the procedure wasn't warranted to diagnose whether

you had it or not. Were you having any other symptoms besides IF, such as

pelvic pain, irregular periods, etc.? These are not IF issues, but gynelogical

issues that are often diagnosed via laparoscopy.

Have you thought of involving a lawyer, or at least threatening to do so? That

might help your case.

Also, do you know if your mom took DES when she was pregnant with you? This can

cause problems with both the uterus and the fallopian tubes (as well as the

cervix). It could provide support for your birth defect theory. Btw, I don't

recall your age or geographic region, but DES was administered after 1971,

especially internationally into the late 70's. I was exposed in early 1971 and

born at the end of 1971, but I know women younger than me who were exposed to

DES as well. The CDC's DES update can be found at

http://www.cdc.gov/des/consumers/download/cdc_des_update.pdf. Also, if your mom

was exposed to DES, you could potentially be affected (research is still

on-going with third-generation DES exposed children).

One other suggestion for your next procedure: Do you have the option of having

two insurance companies (maybe with your husand?) next year? If so, can you

wait until next year? I had two insurances last year and all of my expences

were covered as long as I was going to in network doctors. With all of the

copays and procedure expenses that I had, this helped a lot.

I'm sorry if it seems like I am reaching, but I really wish that I could help

you! If I come up with anything else, I'll let you know! Keep us posted on

your progress!

Good luck & Best wishes,

Mikell, 34

t-shape

28 wks

1 m/c 2/04

October 28, 2005