- Insurance, and a little OT as an example

[Guest guest]

,

This may have been discussed recently already, but I haven't been

following the board as closely as I would like to. My apologies in

particular if you've already addressed this issue as it pertains to

you.

Anyhow, health insurance should NOT be treating MA diagnosis and

surgeries as diagnosis and surgery for the treatment of infertility.

Tests such as HSGs, MRIs, 3d ultrasounds, etc. and surgeries such as

metroplasties (the whole gamut, from lap/hyst resection procedures, to

vaginal septum resections, to the rare case of abdominal procedures -

i.e., Strassman, Thompkins, etc.) are for the diagnosis and treatment

of BIRTH DEFECTS.

Congenital abnormalities generally are not (and in some cases, CAN NOT)

be excluded from coverage, and should be covered at a higher or full

rate, NOT at the same reduced rate that infertility treatment may be

covered at. Surgery required for MAs is for the purpose of returning

the body to " normal " function.

Think of it this way - heck, if the insurance person denying coverage

is male, use this as an example! Some male babies (~1 out of 300) are

born with hypospadias, a condition in which the opening of the urethra

(where urine exits from the penis) is in the wrong place.

Reconstructive surgery involves, in short, putting the opening in the

right place (and creating as cosmetically normal-appearing penis as

possible). If the opening of the urethra is substantially far back on

the penis (or even scrotum), or if it has a severe bend in it, then it

may interfere with urination, sexual intercourse and fertility. So,

does correction of this malformation make it a treatment for

infertility? I THINK NOT! Does it make a difference that surgery for

this condition is typically done between 6 and 18 months of age while

surgery for MAs is typically done as an adult? I THINK NOT!!

While some insurance companies may balk and ultimately not give you any

more coverage, DO NOT let them do this without a fight. In most cases,

framing your issue to them as something OTHER than infertility can be

very successful in getting more coverage.

I can't say this strongly enough. PLEASE, everyone who is still

undergoing diagnostic procedures or looking at resections, MAKE SURE

that you are getting the full amount of benefits that you are entitled

to.

* Make sure that your insurance companies are processing claims for

the dx and tx of a congenital anomaly, and NOT for infertility.

* Make sure that your doctors are coding your treatments and tests for

the dx and tx of a congenital anomaly, and NOT for infertility.

* If need be, emphasize other NON INFERTILITY issues that you may have

in conjunction with your MA to support that this is a congenital

anomaly that warrants proper diagnosis and correction. Do you have

painful periods? Do you have debilitating cramps? Is sex painful? Do

you also have endo and concurrent endo issues?

* If your insurance company still insists that your dx and tx are for

infertility, APPEAL the decision. Have your claim and condition

reviewed by a MEDICAL PROFESSIONAL at the insurance company (not a

claims processor). I believe that our founder, Beth, actually had an

insurance company nurse who helped her get the coverage she was

entitled to, and went so far as to check to make sure she was doing ok.

* Have your doctor intervene in this process if necessary - DO NOT BE

AFRAID TO ASK. Your doc may even have someone on staff who is

experienced in dealing with insurance issues.

* If your employer has a decent HR department, check with them to see

if they have an advocate whose JOB is to intervene on your behalf in

insurance disputes.

< >

Whew. Sorry about the length of this. I just hate to see people not

receive the benefits that they are entitled to (and that they are

PAYING FOR) because some drone thinks that any treatment beyond an

annual exam and any testing beyond an annual pap smear automatically

means infertility which automatically means no or reduced coverage.

< >

Ann

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