Re: insurance companies insisting on using ocps

[Guest guest]

Dear List,

Some attendings have mentioned to me that some

insurance companies will not pay for a hysterectomy if

one has not tried ocps for the patient. If a patient

has DUB or adenomyosis and cyclic progesterone does

not work what could be done if the insurance is

requiring this? Has anyone run into this problem? As

a resident I have not encountered this but I am

wondering how privated practioners handle this. Any

thoughts? Can one state the patient has ethical

objections to the pill if this is the case?

Keefe, MD

[Guest guest]

The insurance companies require a trial of hormone therapy - they can not specify which particular hormone therapy. So I think that a trial of Lupron or progesterone would meet their criteria.

Just be sure that the letter requesting the pre-authorization mentions that hormone therapy was tried x X months and was not successful or tolerated or whatever.

alicia cnm Re: insurance companies insisting on using ocps Dear List,Some attendings have mentioned to me that someinsurance companies will not pay for a hysterectomy ifone has not tried ocps for the patient. If a patienthas DUB or adenomyosis and cyclic progesterone doesnot work what could be done if the insurance isrequiring this? Has anyone run into this problem? Asa resident I have not encountered this but I amwondering how privated practioners handle this. Anythoughts? Can one state the patient has ethicalobjections to the pill if this is the case? Keefe, MD

[Guest guest]

In CA this

happens all the time. The

insurance companies use approved protocols and approved formularies to control

cost. They even used to have a

saying: “Doctors can order anything they want, it just doesn’t mean that it is

covered.” Usually they have a form

and perhaps there is just a check box that states “tried/unsuccessful.” If you are completing an authorization

form than I don’t see any reason why you can’t state that the client has a “moral/ethical”

objection to the standard treatment.

These insurance companies are always talking about “holistic” care and

how they take care of the mind-body-spirit of their patients; perhaps you

should hold their feet to the fire.

I know one

senior physician who retired early because he couldn’t take it anymore. He felt like he had to lie or “bend the

truth” constantly in order to get what his patients needed.

Picella

-----Original

Message-----

From: Keefe C

Sent: Wednesday, October 06, 2004

8:06 PM

To:

nfpprofessionals

Subject: Re:

insurance companies insisting on using ocps

Dear List,

Some attendings have mentioned to me that some

insurance companies will not pay for a hysterectomy if

one has not tried ocps for the patient. If a patient

has DUB or adenomyosis and cyclic progesterone does

not work what could be done if the insurance is

requiring this? Has anyone run into this problem? As

a resident I have not encountered this but I am

wondering how privated practioners handle this. Any

thoughts? Can one state the patient has ethical

objections to the pill if this is the case?

Keefe, MD

[Guest guest]

In obtaining authorization for a hysterectomy, I usually

state " hormonal therapy attempted and not successful " . I am not

specific about the type of hormonal therapy. I have never seen

a " check box " for surgery authorization. Usually we write a paragraph

defending why hysterectomy is the recommended therapy, and includes

documentation such as ultrasound, anemia etc. For example: " G4P4 with

heavy menses; Soaks through clothing; uterus enlarged per ulttraosund

and exam; compatiible with adenomysosis; pt is anemic and on FeSO4.

Hormonal therapy attempted and failed. " This avoids getting into the

whole OC discussion with managed care. It is not lying, but also not

provoking the discussion of OC's. I have never been asked what kind

of hormonal therapy was used, which is almost always bioidentical

progesterone or occasionally Provera. It is reasonable for managed

care companies to ask if medical therapy is attempted before surgery

is done.

M. Davenport

> In CA this happens all the time. The insurance companies use

approved

> protocols and approved formularies to control cost. They even used

to have

> a saying: " Doctors can order anything they want, it just doesn't

mean that

> it is covered. " Usually they have a form and perhaps there is just

a check

> box that states " tried/unsuccessful. " If you are completing an

> authorization form than I don't see any reason why you can't state

that the

> client has a " moral/ethical " objection to the standard treatment.

These

> insurance companies are always talking about " holistic " care and

how they

> take care of the mind-body-spirit of their patients; perhaps you

should hold

> their feet to the fire.

>

> I know one senior physician who retired early because he couldn't

take it

> anymore. He felt like he had to lie or " bend the truth " constantly

in order

> to get what his patients needed.

>

> Picella

>

> Re: insurance companies insisting on

using ocps

>

> Dear List,

>

> Some attendings have mentioned to me that some

> insurance companies will not pay for a hysterectomy if

> one has not tried ocps for the patient. If a patient

> has DUB or adenomyosis and cyclic progesterone does

> not work what could be done if the insurance is

> requiring this? Has anyone run into this problem? As

> a resident I have not encountered this but I am

> wondering how privated practioners handle this. Any

> thoughts? Can one state the patient has ethical

> objections to the pill if this is the case?

>

> Keefe, MD

>

>

>

>

>

>