I need the insurance expert - BIG APPEAL!!! - Infertility Message Board

kateisboo · 05-21-2003, 02:40 PM

Got notification today that I will be allowed a "second level" appeal. I will be given thirty minutes to discuss "my side" and give this board (doctors, lawyers, others) the scoop on why I should have coverage for the things I am requesting. Here's my story:
My insurance lets you have 6 ovulation inductions/monitorings with IUI or not - your choice, then three more without IUI. When IVF rolls around NO COVERAGE. I have not used up all my monitorings and don't understand why the monitoring part of IVF should count as one of the allowed. Also, if you do IVF and for some reason can't do the retrieval and transfer and have to convert to IUI or sex, well then they cover it! I think that is BS...case in point that there is no freakin differnce in the monitoring part. whoever the guru on insurance was a few posts back...can I get some pointers from ya? I want to look like someone with a legitimate claim and not just a whiner trying to scam. What do you guys think, do I have a leg to stand on or just being pesty?

sunnytxgal · 05-21-2003, 03:00 PM

TESSA***WHERE ARE YOU???
She works for an insurance company!

tazink · 05-21-2003, 07:09 PM

The most important thing with insurance companies is money. Compare the cost of what they cover to what they won't. If the cost is the same, the should cover it. Also, try to get your doctor to write up something for you. If IVF is the only way you are going to have a child, I would really push that point and also explain to them that you have exhausted all other sources of trying to get pg. This isn't just a "quick fix" for you b/c you don't want to wait, you have to have it done. Also, find out how much in premium you have paid to the company and how much more you will spend over the years.

I too work for an insurance company and I can honestly say that a lot of them just don't give a fly'n fart about anything other than money. What is wrtitten in the policy is what they are going to go bye. If possible, it may be helpful to have an attorney present.

I would let them know that you are willing to appeal this until the end and that you just can't afford to pay have the procedure done without insurance (which is why you have it) and also again express that it is your only chance to have a child.

Hope some of this is helpful.

Amy

kateisboo · 05-21-2003, 08:40 PM

thanks amy, thought I would give it a try, nothing to lose but money! If they go for it then all the better if not, I am at least where I started. I apprec. the tips!

TessaL · 05-21-2003, 09:02 PM

Here I am!

You've got a pretty good case here.

Lay it out with dollar signs in mind. The cost of them monitoring you and inducing ovulation with IVF in mind as opposed to the cost of monitoring you and inducing ovulation with IUI in mind. Get the RE's office to spell out what the difference is in the cost. My bet- there is little difference. The procedures are the same, the diagnosis is the same. For example- the u/s is going to read the CPT code for Folliculogram ( code is 76857) and the diagnosisis will be whatever your trouble seems to be. In my case, it's "Infertility of unspecified origin" (code is 628.9). Those would read the same no matter WHAT my treatment plan.
I GUARANTEE that your RE's office probably already has a template for a letter they use for appeals. Ask them if you can use some of their verbiage.
You're right about wanting to make sure you sound reasonable and intelligent about this. Unfortunately, the insurance companies main objective is to get you the health care you NEED and still make money. In most states, the state of being infertile is considered an inconvenience, not really a medical issue that HAS to be fixed.
I hope this helps.