WANTED: PEP TALK
I’d like to share my experiences in fighting my insurance company, and ask for some
encouragement.
6-2-04 My gynecologist wrote the following letter to my insurance company:
"Please be advised that I have prescribed for my patient, [Ms. Hir-Fem], electrolysis (procedure code 17380) due to the consequence of a hormonal imbalance resulting in hirsutism. Due to this, I am writing you to clarify the medical necessity of this treatment for my patient.
“Hair removal in this instance is NOT cosmetic for this patient because of the following:
1) This medical condition causes the hair growth.
2) As a physician, I can measure the effectiveness of her medication by monitoring the presence or absence of new hair growth in the areas involved. As no two patients respond in a similar manner, medication may need to be regulated to avoid possible side effects. Therefore, electrolysis would be diagnostic as well as therapeutic.”
8-11-04 Insurance requests the following information from my GYN:
-Letter of medical necessity.
-Areas affected.
-What "hormonal condition"?
-What medications?
-What side effects of medication will observation of new facial hair growth help to avoid?
-Supply a photograph.
?-?-04 I didn’t see the letter my GYN sent, but I can say the following: Areas affected are: black, coarse hair on the chin and neck; some hair on the upper lip; scattered, dark, pubic-like hair on the back; dark, pubic-like hair on the buttocks; black pubic hair on the abdomen, working its way up to the chest; dark, coarse hair on the arms and legs. I have insulin resistance. I’m taking Metformin ER. I gave my GYN a hideous photo of my beard.
9-15-04 Insurance writes:
“Request for electrolysis…denied completely because: per letter of medical necessity, there are no medical problems created by your condition. Therefore it is cosmetic and as such is not a covered benefit of the Pennsylvania Medical Assistance Program.”
10-22-04 I filed a 1st level grievance and wrote:
"The removal of abnormal hair growth by electrolysis is not cosmetic; the only areas that are considered cosmetic are the eyebrows, underarms, bikini line, and raising the hairline on the forehead.
“[Insurance] paid for the medication prescribed for my condition, therefore they will also have to reimburse me for the electrolysis treatments I have been receiving.”
10-26-04 Insurance writes to me, saying that they have received my ‘complaint’.
11-3-04 I have to call the PA Dept of Health to have them tell Insurance that I filed a grievance and not a complaint.
11-4-04 Insurance writes:
“A committee of one or more [Insurance] staff that includes a licensed doctor or dentist, who have not been involved in the issue you filed your grievance about, will review your grievance.”
12-1-04 Insurance writes:
“The first level grievance review committee consisting of a Physician Advisor who is board certified in internal medicine and a Utilization Management Nurse has decided that the denial should be upheld as not medically necessary…because information provided to [Insurance] to date is insufficient in documenting medical reasons as to why electrolysis is needed. Therefore, the requested procedure is determined to be cosmetic in nature.”
1-14-05 I’m ready to file a 2nd level grievance, but my GYN wanted me to include a letter from him when I send it in. His office suggests that I call Insurance and ask for an extension on their 45-day deadline. According to the letter from Insurance dated 12-1-04, I have to file within 45 days from the date I get the notice . This would end on 1-15-05.
I call Insurance and they say the deadline was up on Jan 10th, counting from 11-26-04. Where they got that date from, I don’t know. I went ahead and sent it in anyway.
1-18-05 I filed a 2nd level grievance and wrote:
“I maintain that electrolysis IS medically necessary for the following reasons:
-It was prescribed by [GYN].
-A medical condition has caused abnormal hair growth. (PCOS)
-Electrolysis is the current standard medical practice for hirsutism.”
I included a letter from my GYN stating:
"As I have stated previously, electrolysis is not a cosmetic need but a medical one for [Hir-Fem]. She suffers from hirsutism which is a side effect of poly cystic ovary syndrome. Hirsutism can be defined as “an adult male pattern of hair distribution in women”. Simply put, [Hir-Fem] has very heavy, coarse hair on parts of her body where a female does not generally have hair growth. In addition to this, she suffers from acne. The excess hair growth, along with the acne, can result in ingrown hairs. These ingrown hairs can result in infected hair follicles which can exacerbate both conditions.
“In addition to the physical discomforts caused by hirsutism, the emotional impact can be debilitating. The patient states that she has refused to leave her home at times because of the way she looks and feels. She tries to hide her chin when she is out in public. This is not the way any woman should have to live. She should have quality of life. The electrolysis could certainly go a long way toward providing this for [Hir-Fem].”
1-24-05 I attended the 2nd level grievance meeting and gave this speech:
"It is abnormal and humiliating for a woman to develop the facial hair pattern of a man, the same as it would be for a man to develop the characteristics of a woman. I am tired of feeling like a freak and of having to strategically hide my beard when in public.
“Hirsutism is no more cosmetic than acne is, and [Insurance] pays for acne treatments. I’ve had both of these conditions and can say that hirsutism is much more shameful and socially unacceptable.”
They asked me where I had the hair, my age, and some medical questions. I cried through the whole thing. It was humiliating to have to tell a group of strangers, including a man, these gross things about myself. It’s a good thing that I brought a copy of my GYN’s letter, because they said they didn’t receive anything from him.
3-4-05 Insurance writes:
“The second level grievance committee consisting of a Chief Medical Officer who is board certified in family practice, a Utilization Management Nurse and a [Insurance] Member has decided that the decision to deny electrolysis be upheld…[Insurance] is required by contract with the Commonwealth of Pennsylvania to cover medical services that are medically necessary…[Insurance] has not been provided with documentation to support a medical need.”
3-14-05 I requested an external review and a copy of the company’s criteria for a medical necessity.
3-18-05 Insurance tells me that they sent the request to the PA Dept of Health.
3-21-05 PA Dept of Health writes to me that they have assigned my grievance to “an independent and external review organization called a Certified Review Entity (CRE).”
According to their rules, I have to send a copy of what information I give to the CRE to Insurance also. Insurance is also supposed to send a list of what they send to the CRE to me within 15 days that they received my appeal request. I have never received this.
3-31-05 I sent the CRE the following:
-A copy of my Dr.s diagnosis of Hirsutism and PCOS.
-My GYN's prescription for electrolysis.
-My letters requesting 1st and 2nd level grievances.
-GYN's 2nd letter.
-Comments I made at the 2nd level meeting.
-5 X 7" photo of my beard.
4-14-05 CRE writes:
“The health plan’s original denial is: Upheld”
The reviewer is board certified in OB/GYN and Reproductive Endocrinology and Infertility. Their list of credentials is intimidating; having won awards, written over 70 articles, being a member of many pro medical organizations, and being the Director of this and that.
The reviewer wrote:
“The treatment is not medically necessary. According to the American Society for Reproductive Medicine Practice Committee, “Hirsutism is a common complaint, often of significant cosmetic concern, usually resulting from increased androgenic activity. Hirsutism usually does not signify major pathology…” …Hirsutism is considered a “cosmetic concern” by the ASRM- “Patients who suffer from hirsutism require long term follow up and emotional support.””
As a side point, I received from Insurance their definition of medical necessity (after my deadline to file info with the CRE), which lists 3 standards for a covered benefit. They say if any one of them is satisfied, then the service will be considered medically necessary. The second is: “The service or benefit will, or is reasonably expected to reduce or ameliorate [improve] the physical, mental, or developmental effects of an illness, condition, injury, or disability.”
5-19-05 I ask for HELP!!! Do I have a chance in court?
