Medically unnecessary

Medically unnecessary. Those were the words printed in large letters across a document of denial I'd recently received from my insurance company. My oncologist had ordered a new type of recirculating compression pump to alleviate the extreme swelling in my upper extremities. This condition, called Lymphedema, had occurred shortly after I'd been through surgery to remove both of my breasts and several lymph nodes in each arm. As I read the letter, I became very upset. As I re-read the letter, I became angry. How dare these insurance company agents determine what is and what is not necessary for my health? Shouldn't my oncologist be more educated in matters pertaining to breast cancer and the side effects? I certainly thought so. Toward the end of the letter, after the insurance company had supplied their standard explanation for the denial, were instructions on how to submit an appeal. Finally, a ray of hope! I was definitely going to do that, but first, I had to contact my oncologist and prepare for battle.

The insurance letter stated I had "not exhausted all means to reduce the swelling." They said I "had not tried other methods available" and I had not "tried exercise, massage, raising the affected part, or elastic bandages and garments." They said they "didn't see where other treatments were tried and didn't work for you." Boy, did I have some information coming their way as I prepared to submit my appeal. I read on and the letter of denial said, "This decision doesn't mean that you can't or shouldn't receive this service. Only you and your health care providers can decide whether you need it. But, this decision means that if you do receive the service, it won't be covered by your plan." We'll see about that, I thought to myself. The insurance company had no idea what I'd been through over the past year and a half and how I'd tried so many things to treat this uncomfortable condition.

I made a call to my oncologist's office and left a message for my doctor. I told him about the denial letter and asked if he'd be willing to submit more documentation to substantiate the medical need for the equipment he'd ordered for me. His assistant assured me she'd get the message to him and there would be no problem in him providing whatever the insurance company needed to appeal the claim. I was thankful to have that assurance tucked safely in my arsenal.

After speaking with my oncologist and giving him a "heads up" about the denial from the insurance company, I contacted the company that manufactures the recirculating compression pump. I talked with a representative there and told her about the denial letter I'd received and asked what I needed to do to provide them with more information as they had agreed to also submit a request for review and reconsideration. The representative suggested I take photographs of the swelling and submit those along with a handwritten, personal testimony of how Lymphedema has impacted my life. Her suggestions seemed like very valid ways to present my case. I thanked her and agreed to copy her on my letter. I had no idea how to write an appeal letter to an insurance company. I didn't know what they needed to change their minds about whether the equipment was medically necessary, but I was going to give it my best shot.

As I waited for my computer to boot up, I gathered my medical notebook where I'd kept a record of each and every lab result, test, surgery or medication since I was diagnosed with breast cancer. The notebook had started out completely empty and now was almost 3 inches thick with medical records. I flipped through the notebook marking pertinent information with sticky notes so I could refer back to them easily as I prepared my letter. I opened a blank document in my word processor and began to write my letter. I was surprised at how easily the words came to me. I decided not to fill the letter with medical jargon, although I knew that was something the insurance company would easily understand, instead I decided to write the letter so they'd feel my heart...that they'd understand I was a real person with valid health issues. I wanted them to know what it felt like to wake up first thing every morning with arms so swollen and painful that it was difficult to get out of bed. I wrote about not only the physical limitations Lymphedema imposed on my life, but also about the pain and humiliation that went along with it. I explained the swelling has increased the girth of my upper arms so much that I have great difficulty finding shirts and blouses that I can even get my arms into the sleeves. I wanted them to understand the swelling gets worse as the day goes on and often, by midday, I have to sit with my arms elevated for a hour or so, because they are so swollen and sore, before I can continue my normal household duties. I followed the representative's advice and listed every single treatment I'd tried to combat the Lymphedema. I put dates and locations. I even took my cell phone and snapped photos of my bare chest and upper arms so the insurance agents could see what I was trying to explain. My letter, by the time I'd completed it, was three pages long. I felt like I'd done my best to provide adequate information for reconsideration of my claim.

It's so frustrating to have to defend myself to the insurance company. We pay our insurance premiums on time every single month and have for over 35 years. Why is it, that when they decide they don't want to pay out a large sum of money for a fairly new medical treatment, the claim is instantly denied? I wonder if most cancer patients who receive a denial take the time to fight back or if they just accept defeat and end up paying for whatever they need out of pocket. It seems a very unfair injustice is done to those of us who have already been through the trenches of war in a battle we never chose for ourselves and then, to have to fight for what insurance companies deem medically unnecessary. It just doesn't make sense.

Yes, I understand the insurance companies want to find ways to hold on to their money and avoid paying unnecessary or unsubstantiated claims, but good grief, don't they think an oncologist is the best one to decide their patient needs? All that medical schooling to specialize in the field of diagnosing and treating cancer must give them a whole lot more expertise than a few board members sitting around a table at an insurance review board, don't you think? I sure do and I would advise any patient to stand up and fight for their rights. The letter said, in big bold letters, "You have the right to file an appeal." And that's just what I did. Now I have to wait and see what happens next. I'm praying the documentation I provided will be enough and even if mine isn't quite what they need, perhaps my doctors' information will cause a reversal of the denial of the claim. Medically unnecessary...I wonder how those insurance agents would feel if they received that same type of denial letter when seeking treatment for one of their loved ones? I bet they'd seek an appeal, too.

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