Insurance Denial of "Upgrade"

Hi all,

I have a dual chamber pacemaker (100% dependent). I am in heart failure because the bottom left chamber of my heart has quit working. My cardiologist wants to upgrade my pacemaker and put in an extra lead into that chamber. I really need the surgery because I am having some pretty severe symptoms. However, my health insurance denied the procedure. Does anyone have any ideas or resources out there that could be of any help?

12 Comments

I would..

by MelodyMarch - 2014-03-23 09:03:05

call the insurance company myself, and get their end of it. Sometimes they need more information from the doctor (i.e. more tests). I have heard of some insurances denying the CRT's if your EF is still considered "too high". To get my pacemaker, my doctor because of my age had to call and say that I was in danger of hurting myself more, and possibly others with my passing out, along with a 48-hour holter test of documentation.

There are also patient advocates that can work with the insurance companies and hospitals. Most hospital websites have information on that.

Hope this helps!

We're not ignoring you cheree

by Grateful Heart - 2014-03-23 10:03:20

I think we are all in a state of shock (no pun intended).

Did they give a reason for denial?

Like Melody said, maybe they are missing some info or it was coded wrong. Have you spoken with your Doctor yet? I would start there.

Please find out more information and let us know. This is a concern for all of us and we don't want anyone to panic.

Grateful Heart

Scared

by chereescott - 2014-03-23 10:03:28

I have spoken with the insurance company and my doctor's office at length. My insurance company said that I have to be in the severest form of heart failure (basically on death's door) before they will approve it. They say that at at this stage it is considered "experimental" and "not medically necessary". My doctor's office says my health insurance is the worst one to deal with. We have appealed and it was denied again. I am basically in bed 75-80% of the time and my quality of life is zero. I am scared I am going to lose my job and at my wits end. I don't know what to do.

Appalling

by NiceNiecey - 2014-03-23 11:03:22

That is horrible. If it were me, I'd ask the doctor if I could make payment and get it put put in with my insurance company's approval. What's worse? Functioning only 20-25% of the time? Or having an interest-free loan to get it done? Just do it. I have kids your age and would feel horrible if they were in your position.
Niecey

Make that WITHOUT

by NiceNiecey - 2014-03-23 11:03:49

Typo above; sorry. Do it WITHOUT insurance approval

Medically Necessary

by Grateful Heart - 2014-03-23 11:03:53

If your left ventricle is not working, that is obviously medically necessary....nothing experimental about it.

You have spoken with your Doctor's office, but what does the Doctor say? Did he/ she give you any suggestions. I don't know what insurance company you have but I would think he could prove it was medically necessary.

Not trying to push you, just trying to get more info.

Grateful Heart

Just an observation from afar

by IAN MC - 2014-03-24 01:03:57

During the 3 years or so that I have been following the PM club there have been dozens of posts , all from America, all asking the question " I live in the USA, I am ill , I desperately need treatment but I can't afford it / my insurance won"t pay for it ! "

Not once has there been a reply from the poster saying
" I solved it by doing X ". I'm sure they can't all have perished, never to be heard of again ?

I find it impossible to believe that you will not get the treatment you need to improve your quality of life ; you are not a 3rd world country !

Would you be the exception ,Cheree, and please let us know how you get on ; everyone is concerned about you

Best of luck

Ian

Here's the link for the GA State...

by donr - 2014-03-24 06:03:27

....Insurance Commissioner:

http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CCcQFjAA&url=http%3A%2F%2Fwww.oci.ga.gov%2F&ei=AfkvU4b_BsbD0AGmyoCYBA&usg=AFQjCNG1aWA8yprYJMsXF7iwr8ZrXw3SzQ&bvm=bv.62922401,d.dmQ

Contact them for starters.

A question: Did you have your original Pre-Obamacare insurance cancelled?

Is this replacement insurance acquired post Obamacare?

Donr

Help MAY be at Hand...

by donr - 2014-03-24 10:03:02

...Cheree: Pls send me a Pvt Msg for details. Recall that I tried to locate a new primary Care Physician for you two yrs ago.

Talked to a Cardio nurse friend today who worked for a Cardio who cared for MANY PM hosts. He is here in the Greater Atlanta area.

She gave me some good - I hope - guidance to pass on to you.

Don

Donr

by Grateful Heart - 2014-03-24 11:03:06

You are a man among men.

Grateful Heart

Georgia

by Grateful Heart - 2014-03-24 12:03:04

I see from another post you live in Georgia.

If you've exhausted all options and Doctor's suggestions, find out who your local State Senator is and ask for their help.

Grateful Heart

Donr

by Ck - 2014-03-28 08:03:17

Ditto on Grateful's comment.

On behalf of cheree and others like her, I thank you for your dedication to this site.

@cheree, I contacted my state Senator about an issue, and went to the meeting thinking he would pat me on the head and send me on my way. The exact opposite happened! He has been my strongest advocate, and continually amazes me with his passion.

I tell you this so that you will not be afraid to contact your Senator. I would bet he/she would be just as passionate for you.

You know you're wired when...

The mortgage on your device is more than your house.

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