How to take the choice away for the insurance company?

[Debbrn]

I spoke with BC/BS of Alabama today. To my astonishment, they will only
pay for a cadavar valve when a tisssue valve is needed. I have already spoken to the human resources manager at work to start the fight. Any information would be appreciated.

I am NOT going to let the insurance company choice what valve I get.

Debbie

 

[MikeHeim]

I don't have any information regarding this, but I wish you well in your fight.

Frankly, I'm surprised that insurance companies allow us patients as much leeway with valve choice as we have. Tissue valves, especially in us younger folk, will require multiple surgeries over a lifetime. Clearly that would come at a much greater cost to the insurance company than would the single placement of a mechanical valve and a lifetime of Coumadin management. That said, I was thankful to have had a choice (backup plan that I ended up not needing) and chose tissue. Furthermore, I'm surprised that countries with socialized medicine do not do more to dictate valve choice. Hopefully the freedom to choose is not taken away in the future.

 

[sknydave]

I've had surgeries denied by insurance companies before.

Have your surgeon write a letter on your behalf. I'm sure he's been in that boat many times.

 

[AgilityDog]

Maybe your surgeon needs to start the pre-auth process to determine coverage. I sure hope you just got hold of someone who is confused. Heaven knows UHC can't give anyone a straight answer on coverage for even a routine mammogram, at least not by telephone!

 

[Debbrn]

I have fantastic news!!!! The director of human resources called me to say that they would pay for a pig, but not cow valve. BC/BS called me back a couple hours later and apoligized. They said that on "further research" they would pay for a pig or cow valve.

The reason I will have a tissue valve is because I will need my pulmonary valve replaced again. Tissue valves are generally used in the pulmonary position.

Debbie

 

[AgilityDog]

That makes sense. And supports my theory that you can't get a straight answer from the insurance co.--like calling the IRS, they're wrong 60% of the time. Snicker. Great news, though.

 

[Lisa in Katy]

That's good news! I was going to say that you could argue that they are all cadaver valves - the donors are all dead!

 

[Karlynn]

I am the last to understand why insurance companies think the way they do. BC/BS let the provider of my INRatio machine charge them almost 2 times the cost of it. And they let them charge 2.5 times the cost of the strips. To top it all off, when the last bill for stips came back as not covered - we called and they said I had not proved that I needed to home test. This was after they approved the purchase of the machine that they paid a king's ransom for.

 

[Superbob]

Debbie,

Fantastic you got that cleared up right away. Sometimes such battles can rage for a long time and sometimes they're never satisfactorily resolved.

 

[Debbrn]

I actually have a cadavar aortic valve in my pulmonic space right now. It has been in my body for over 17 years and is getting tired and is leaking a lot.

I think that problem was that BC was looking in the computor incorrectly. They were looking it up under transplant guidelines I am assuming.

Debbie