Can insurance dictate what is the size for Thoracic aneurysm repair in US

[dixitworld]

Hi All,

I am 31/M and I already had Aortic valve replacement done with Mechanical valve in 2010. Now my ascending Aorta is 5.2 cm. Local surgeons have recommended surgery at this stage. I am in process of having one more discussion with surgeon at Cleveland Clinic.I heard somewhere that can Insurance say no for my surgery as size of my Aorta has not reached 5.5 cm? I Have United Healthcare insurance.

Locally surgeon told me that for a second surgery these numbers doesn't hold true and since my aneurysm is increasing every year its right time for treatment. Although they didn't spoke anything about insurance.

I am not much familiar with insurance rules here in US so just want to understand if others have any opinion and if insurance can create some trouble whats the best way to tackle with them.

 

[dixitworld]

My Aortic Size Index = 2.75 and Cross-sectional Area to Height Ratio = 12.5
I had history of bicuspid aortic valve and these numbers does show i am at risk now.

 

[dick0236]

Hi All,

I am 31/M and I already had Aortic valve replacement done with Mechanical valve in 2010. Now my ascending Aorta is 5.2 cm. Local surgeons have recommended surgery at this stage. I am in process of having one more discussion with surgeon at Cleveland Clinic.I heard somewhere that can Insurance say no for my surgery as size of my Aorta has not reached 5.5 cm? I Have United Healthcare insurance.

Locally surgeon told me that for a second surgery these numbers doesn't hold true and since my aneurysm is increasing every year its right time for treatment. Although they didn't spoke anything about insurance.

I am not much familiar with insurance rules here in US so just want to understand if others have any opinion and if insurance can create some trouble whats the best way to tackle with them.

I never put much stock in things "I heard somewhere". The only way to be sure of the insurance coverage is to talk to United Healthcare. Call them, or talk to your HR person.......or both. If they have policy restrictions and your surgeon believes yours is a special case have his office, and your HR dept.l, help you in stating your case for an exception. That's a bummer to need the second surgery because of an aneurysm.

BTW.....although I have been retired 20 years, I worked as a health insurance consultant for twenty five years prior to retirement and found that insurers do not do not look for ways to refuse legitimate claims. I've seen a lot more questionable claims get paid than I've seen claims turned down.......in the so called grey areas.

 

[dixitworld]

I never put much stock in things "I heard somewhere". The only way to be sure of the insurance coverage is to talk to United Healthcare. Call them, or talk to your HR person.......or both. If they have policy restrictions and your surgeon believes yours is a special case have his office, and your HR dept.l, help you in stating your case for an exception. That's a bummer to need the second surgery because of an aneurysm.

BTW.....although I have been retired 20 years, I worked as a health insurance consultant for twenty five years prior to retirement and found that insurers do not do not look for ways to refuse legitimate claims. I've seen a lot more questionable claims get paid than I've seen claims turned down.......in the so called grey areas.

Thank you dear. I did called insurance tens of times and the agents who sit there just say to me they don't know medical procedures and what not. They say once they will receive the pre authorization request they can deny if they don't think it is right.

 

[dick0236]

........They say once they will receive the pre authorization request they can deny if they don't think it is right.

That's where you get the ball rolling. Have the surgeon submit the authorization request with the medical details. If they deny the surgery then you can appeal their decision and if it is determined, after they consult with your surgeon, that the surgery is needed they will approve the procedure. If you work for a larger company you should have someone in the Human Resources office that can help you.

 

[Warrick]

Thank you dear. I did called insurance tens of times and the agents who sit there just say to me they don't know medical procedures and what not. They say once they will receive the pre authorization request they can deny if they don't think it is right.

From my own experience in my country but I can't see why it wouldn't be world wide
it's not some office secretary deciding the claim it's a medical team that take the information, test results and recommendations from your own doctors who are experts in their field and then make the call

 

[tom in MO]

All non-emergency surgery is subject to review by your insurance company. Your doctors and surgeons know this and they know what is generally acceptable; you should not get any surprises. In my experience, I've never had any surgery turned down. I did have to justify a medication received as an implant, but that just took an explanatory letter from my doctor.

 

[cldlhd]

In 2015 I had surgery on mine and according to the scans it was either 4.7 or 4.8cm and my surgeon said I was on 'the cusp" of needing surgery but he recommended it and the insurance paid.