Insurance denial for a THR???

[Guest guest]

When I had my resurfacing surgery last year, I had Highmark Blue Cross/Blue

Shield of Western Pennsylvania, and they paid my entire bill. I even got

preapproval twice from them, so they knew exactly what the procedure involved.

My employer has since changed my insurance coverage to a Point of Service (POS)

run by Highmark Blue Cross/Blue Shield of Western PA.

When problems developed with my resurfaced hip a few months ago, I had to return

to the doctor who performed the surgery--Dr. Victor Goldberg in Cleveland, OH.

Unfortunately, he is now considered an " out-of-network " physician, and that

caused all sorts of insurance problems.

Regardless, I went and had Dr. Goldberg perform additional surgery on me in

which he had to revise my hip with a large-head THR. When the insurance company

tried to deny some of the payment because I used and out-of-network physician, I

appealed. My argument was that no in-network physician had a clue about hip

resurfacing, so how could they make a diagnosis or effect a repair, if it could

be repaired?

Today I received a letter from the insurance company conceding that they erred

in saying that I should have gone to and in-network surgeon. However, they are

now claiming that they do not pay for experimental surgery, so they intend to

denying ALL payment for my revision surgery. Can you believe that? They want

to deny payment for a traditional THR because it replaced an experimental

resurfaced hip!

All they've succeeded in doing is making me mad. They don't know who they're

dealing with. I used to be an administrative law judge, and my job was

conducting appeal hearings. This could get interesting.

ph K. Waltenbaugh

Conserve Plus 12/3/02

Conserve Total 12/9/03

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