"Cleveland, Kyle E." <[log in to unmask]> wrote:when u are dealing with the insurance think good thoughts.

genia
Yeah, except that I'm a left-hemi and the tumor is on the right. They've
considered the CP with respect to anesthaesia, and there was a phone
consultation with my orthopedic surgeon and physiatrist (both local at Ohio
State University--the bone cutter's a good one, but the physical medicine
guy lacks experience with adult CPers).

Even though cancer is the dx, there is also a condition in males,
gynecomastia, that causes swelling of breast tissue. Unbelievably, even
though the "swelling" in my case is a malignancy, the insurance company
initially told the surgeon that there would be no coverage because he used
the word "gynecomastia" in the dx description and the ins. co.'s
applications are coded to reject pre-approvals based on keywords.
Gynecomastia is one of them. They will not pay for breast reduction
surgery, and this gynecomastia is the dx "word" for enlarged breast tissue
in men. So, my doctor had to get on the phone and try to explain to this
yay-hoo that I didn't have cosmetic gynecomastia, but "gynecomastia due to
malignant neoplasm". I guess he went round-and-round with this idiot in
pre-auth over the word. Something like this:

Pre-auth: "Dr., we don't pay for gynecomastic reduction."

Surgeon: "The guy has breast cancer. I just put 'gynecomastic reduction' in
the paperwork because that was the closest code on your form."

Pre-auth: "But you checked 'gynecomastic reduction', right?"

Surgeon: "Yeah, but only because that was the closest code."

Pre-auth: "Sorry, doctor, but we don't pay for gynecomastic reduction."

Etc., etc.

All my doctor friends say that dealing with insurance companies is ten times
harder on the physician than the patient. I can believe it! My pain doc
says he spends more time doing insurance paperwork than he actually spends
with patients. The system is "broke" and it's only getting "broker".

Kyle


-----Original Message-----
From: Trisha Cummings [mailto:[log in to unmask]]
Sent: Tuesday, July 29, 2003 9:19 AM
To: [log in to unmask]
Subject: Re: Hey all


Hi Kyle,

I would think you would need recontructive surgury - as don't you have
spasms? You could seriously injure yourself if the incision and surrounding
area aren't pieced together well. Have they taken your CP into account? I
would get a another opinion - generally one is allowed 2nd and 3rd opinions
- if all recommend reconstructive surgery then you have leverage. So perhaps
a CP expert would be in order.

Trisha


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