Radiofrequency Ablation is in the cards for Gale918 (Page 2 of 2)

Thanks so much for the encouragement.  I see the oncologist today.  I want to see what she can do to help.

I am going through with the RFA.  The hospital will get a monthly check for the rest of my life.  I think I will go through with the external review.  That way if we decided to sue in the future, we can.  I'm waiting for a date for the surgery.  I called the State Insurance Commissioner's office and she said that IF this external review rules in my favor, then the insurance company will reimburse me for the surgery.   Chat later.

My RFA is scheduled for January 5th.  I'll be paying for the surgery for the rest of my life.  I am preparing for the External Review with the New Hampshire State Insurance Commissioner.  It's a board of doctors, I was told and I have a 50/50 chance of getting my refusal reversed.

Gale ... you sound to be very pro-active! I talked to the hospital insurance specialist. She indicated that each hospital works differently when it comes to working with insurance providers. A doctor can put together a letter of necessity, arguing for why a patient should receive a certain service, substantiating the necessity for the procedure. This can be performed as an appeal if the patient is initially denied. She also indicated that a patient can contact their congressman, for instances when charges are denied by the insurance company.   A proactive congressman's office, she notes, can research and see if there is a way to work around this either by finding a grant to help, or by offering suggestions on how to proceed.

Good luck to you on the 5th, you are in our thoughts!

Best,
Tess

Dear Gale:

Here is something to think about: When I had my radiofrequency ablation, I was surprised to discover on the day I was admitted that I was on the surgical schedule for a "liver resection".  When I asked the surgeon about this, he said "don't worry; we are going to do RFA". Interestingly, all my medical records say "resection", and the hospital bill and insurance claim both said "resection". Virtually all insurance companies will pay for a resection. I had no trouble getting my procedure approved and paid for by the insurance company.

I would not want to use this forum to advocate anything shady or illegal, but perhaps you might share this story with your surgeon. It might give him some very creative ideas....

Violarob in Texas

Hi Violarob & Gale, Interesting is right. I talked to the insurance specialist about this and she indicated that the docs would have to submit a diagnosis code to the insurance company and she recommended googling "diagnosis code" for RFA and resection. I just came into a BC&BS Medical Policy (Mississippi), noting the following:

"6/19/2007: Policy statement updated; RFA as a primary treatment of hepatic metastases from colorectal cancer in the absence of extrahepatic metastatic disease may be considered medically necessary when the tumor cannot be removed by surgical resection, or precluded by underlying condition(s), and when all tumor foci can be treated. Added RFA for hepatic metastases from colorectal cancer that do not meet policy criteria, and from other types of cancer is considered investigational to policy statement."

(source: http://www.bcbsms.com/index.php?q=provi … tion.html)

Perhaps some BCBS regional policies might cover RFA, while others would not? Perhaps secretaries of leading RFA providers would be able to provide insights into how they do it, or perhaps justification for different coding possibilities?

Best,
Tess