Monday, January 14, 2013

2nd Level Appeal Letter to Humana

Dear Blogging Friends: I have been asked for details on my Second Level Appeal Letter sent to Humana, my Health Insurance Carrier.  Here is what I wrote:

January 14, 2013

To Whom It May Concern:

In review of the processing of the claim for DOS 10.09.2012 by each of the providers who rendered services to me [Mickey Gierhart, Don Dodson, Ameripath Pathology Labs,  Joseph McWherter, Texas Health Resources/Harris Methodist Hospital], I am going to dispute your decision and ask you to reconsider for the following reasons:

The reason for a complete hysterectomy was not due to or related to Endometriosis.  If you were to review the medical records from my physician, Dr. Joseph McWherter for the 1.5 – 2 years prior to this surgical procedure, you would find clinical based evidence that my quality of life was severely compromised due to extreme hormone imbalances that was creating a major strain on my physical body.  I was experiencing severe insomnia and sleep issues, only getting an average of 3-4 hours of sleep a night for a year and a half, when I normally had been getting 9-12 hours of sleep a night.  My sleep issues did not improve even with treatment with Ambian or Lunesta (both which were covered by my Humana Insurance Plan).  The hormone imbalance was creating a significant drain on my adrenals which made symptoms of fatigue and treatment nearly impossible.  Response to compound medications and adrenal supplements (not covered by my Humana Insurance Plan) were minimal due to the ongoing hormone imbalance that was unable to be obtained through hormone therapy (which also was covered by my Humana Insurance Plan).  Various forms of hormone therapy treatments were attempted to discontinue the menstrual bleeding that was occurring up to 10 months straight.  Vitamin B-12 Shots had to be given to reduce the increased risk of Anemia due to the ongoing bleeding.  However, the symptoms continued as my body was non-responsive to these various forms of hormone therapy.  Additionally, due to the severe hormone imbalance and sleep deprivation I was experiencing, the stress on my body from the ongoing fatigue created consequent issues in which I lost 1/3 of my hair.  This was due to my body being unable to cope with these continued hormone imbalance issues and the lack of rest that one needs to heal and live daily life.  My physician, Dr. Joseph McWherter, would request lab work and adrenal tests (which were covered by my Humana Insurance Plan) every few months to try to review what other aspects might be affecting the hormone imbalance.  When these results did not provide answers, a referral was processed to an Internal Medicine Physician, Dr. Mai Sharaf, to obtain a second opinion and request to have my lab work and test results reviewed to determine if there could be an underlying disease or other abnormal condition that would be creating the problems I was experiencing.  After a great length of time spent to find answers through repeat tests, continued alterations made to medication dosage, various sleep aid medications treatments attempted, comparison reports done between test results, findings reviewed and discussed with other specialists and collaborating physicians, other potential diseases ruled out, a negative premenopausal state confirmed, and yet there still no explanation for the reason for my symptoms.  We were now at the complete end of options and still had not gotten any positive findings to figuring out what was transpiring with my body to come to a clinical conclusion to make my symptoms resolved.  At this point in time, Dr. McWherter knew I was very frustrated and dealing with this situation was taking a physical toll on me.  We had exhausted all resources and options for treatment and he was left with only one recommendation, which is what he made to me.  His request was that I consider and pursue a complete hysterectomy.  At 35 years of age, not married, never having been a mother, this was not something I wanted to consider.  However, in reviewing the situation, due to the lack of response to various treatment recommendations and no conclusive reason for the symptoms, I either had to accept the ongoing lack of quality of life that was rapidly decreasing further and putting a complete physical strain on my mental, physical and emotional state and hindering my daily life, or I was going to be forced to make the decision to have an operation to not further progress my physical state and create additional complex health issues.  It became obvious to me that my physician’s recommendation for surgery was the best and only option I had.  I knew that if I was already seeing other things being displayed from the ongoing fatigue and stress on my body, it would only be a matter of time before other symptoms and medical conditions would present themselves and cause further issues to address.  It is because of all these things that I had a complete hysterectomy on Tuesday, October 9th, 2012.

Therefore, because of the reasons outlined above, it is determined that you have inaccurately denied payment for this surgical procedure by stating that it is related to the Exclusionary Rider on the members policy and that it is a non-covered condition [referring to an Exclusionary Rider that was put in place under my Humana Insurance Plan at the time the policy was issued 02.01.2011].  Hormone imbalance, adrenal fatigue, menstrual bleeding, insomnia and hair loss are not related to Endometriosis or Adhesions.  Humana covered and paid for the office visits, medications to treat the symptoms, lab work to determine the cause of the symptoms, tests run to diagnosis, treat, and monitor these conditions.  What gives Humana the right to decline payment for the surgical procedure to resolve the problem?  By denying payment for this surgical procedure, you are in essence stating that you would have rather have continued to pay for monthly office visits for examination and follow-up for monitoring of medication, additional consultations to specialist, further tests to rule out additional medical conditions, repeated lab work, expensive medications, ultra sounds, x-rays and other forms of medical procedures, all the while I was and would continue to be suffering beyond words.  It is hard to explain to you what it felt like having exhausted all options to reasonably treat the symptoms I was facing, come to a medical decision making process that would resolve the situation and improve my quality of life when you only have one option left.  The fact was clear, what I was experiencing in my horrific lack of quality of life that was completely debilitating, to the point I wondered how much longer I could take any of this and not literally die from sheer exhaustion and fatigue, let alone deal with continued months of menstrual bleeding was not something that I felt I could continue to do.  Evidently you think it is reasonable to ask a patient to accept this type of quality of life and to not seek resolution to these symptoms.  Additionally, you have obviously not done the math as to the cost of each of these items or you would find that all those things mentioned above over time are more costly and exceed the cost of surgery.  I believe if you step back and look at the facts presented here you will see that your decision was made without appropriate information and without any clinical understanding and made a judgment call in error stating that it is related to a condition that you have excluded from being a covered benefit under my Humana Insurance Plan which cannot be supported. 

I also would ask you to consider how you feel as an Insurance Payor that you have more clinical expertise then that of my physician?  I think we both can agree that the evidence is substantial to support the fact that your decision was based off of revenue and not one in the best interest of the patient and that you have neither the expertise nor the ability to supersede that of a physician who has been involved in my medical history and been providing medical care to me since 2007.  It is beyond me why Humana would not be in favor of a patient’s health condition and evaluate the situation based off of the facts. 

I am requesting an unbiased, clinical, factual review of my medical history as it relates to all services performed on October 9th, 2012 and a favorable redetermination of claim payment made.


Misty Gilbert
[address and phone number removed for confidentiality reasons]

CC:          Mickey Gierhart
Don Dodson
Ameripath Pathology Labs
Joseph McWherter
Texas Health Resources/Harris Methodist Hospital

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