Question
What is the name of your state?What is the name of your state? Michigan
My insurance provider (Empire BC/BS, based in NY State) has denied payment for removal of a skin lesion, claiming it was not medically necessary because of the diagnosis (seborrheic keratosis; total cost $550). Upon the first denial, I submitted an appeal with a letter from my physician stating that the procedure was necessary to rule out malignancy, as well as medical records as requested by the insurance. It was again denied (same reason) and I was told I could file a second appeal, which I did, with another letter from my physician (more specific, stating that the lesion had changed during my recent pregnancy and was irritated). It was again denied. This time, I was told that because my physician mentioned only that the lesion had changed during pregnancy (not that it had enlarged or changed color) and that it was irritated (but did not specifically mention itching or bleeding) that this did not meet qualifications for medical necessity.
Because it took several months to exhaust both appeals, I have now passed the time limit for applying for an external appeal from the state of NY (45 days from the date of final adverse determination from the first level of appeal). Because I live in MI, I was not aware of this time limit, or I would not have submitted the second appeal! I was not informed of this time limit, nor of my right to an external appeal, by Empire in their correspondence.
I am absolutely certain that this procedure was medically necessary (it may or may not be worth noting that I am a physician myself), but I am not certain how well this was documented in the original procedure note. Can I sue Empire in small claims court? If so, do I do so in NY or Michigan? If I am able to prove medical necessity to the court, is this sufficient?
Thank you so much.
Answer
What is the name of your state?What is the name of your state? Michigan
My insurance provider (Empire BC/BS, based in NY State) has denied payment for removal of a skin lesion, claiming it was not medically necessary because of the diagnosis (seborrheic keratosis; total cost $550). Upon the first denial, I submitted an appeal with a letter from my physician stating that the procedure was necessary to rule out malignancy, as well as medical records as requested by the insurance. It was again denied (same reason) and I was told I could file a second appeal, which I did, with another letter from my physician (more specific, stating that the lesion had changed during my recent pregnancy and was irritated). It was again denied. This time, I was told that because my physician mentioned only that the lesion had changed during pregnancy (not that it had enlarged or changed color) and that it was irritated (but did not specifically mention itching or bleeding) that this did not meet qualifications for medical necessity.
Because it took several months to exhaust both appeals, I have now passed the time limit for applying for an external appeal from the state of NY (45 days from the date of final adverse determination from the first level of appeal). Because I live in MI, I was not aware of this time limit, or I would not have submitted the second appeal! I was not informed of this time limit, nor of my right to an external appeal, by Empire in their correspondence.
I am absolutely certain that this procedure was medically necessary (it may or may not be worth noting that I am a physician myself), but I am not certain how well this was documented in the original procedure note. Can I sue Empire in small claims court? If so, do I do so in NY or Michigan? If I am able to prove medical necessity to the court, is this sufficient?
Thank you so much.
You could still file the external appeal, framing the appeal in such a manner as to explain that you were not advised as to the option and unable to because of being required to file the other 2 appeals and the time required to process them, there should be language in the external appeal to allow for a stay under certain circumstances.
Now onto other matters. I have been through this same runaround but with a test where the HMO intentionally performed the test incorrectly, resulting in a false negative, after I submitted my CME for that very test! I obtained the test data and sent it off to a colleague who wrote the protocol, wherein he confirmed the test was not properly administered and no clinical conclusion could be drawn, I made my appeals with confidence but they were still denied! Luckily I had other insurance, had to go through the whole process again and only at the last minute did they finally approve the test so I was able to have the test done at a major teaching hospital not associated with either HMO, the test was positive! Still the first HMO refused to accept that they were wrong, except for my neurologist who accepted the test results. There is more but that is not the point, the point is unless it is a matter of life and death it is not going to be worth your time to pursue this even though you may be able to justify the medical justification. WHile you may be able to sue in SCC, you won't be able to sue for your lost time, more than $550 to sit in court all day.
As a physician, you know that pregnancy may cause various reactions, including but not limited to: seborrheic keratosis and that while unsightly they are usually benign. Most HMO's and insurance don't pay for their removal unless medically necessary and the greater cost was for the biopsy, which you could have declined. I had to have some things removed after my last pregnancy but I have other medical conditions to justify their removal.
Answer
Removal of a seborrheic keratosis is a cosmetic procedure and is not considered medically necessary in most cases. You can appeal in small claims court if you like but I doubt it will change the outcome. It sounds to me like you and your dermatologist are trying to manipulate a claim to get it paid.
Answer
I am surprised that the physician is not appealing this with Empire, that you are.
However, it is probably too late for him to step in now.
You can not change medical records to suit your needs to get this claim paid, you are well aware of that, I am sure.
You need to ask the dermatologist for a reduced fee and just pay it. He knows what has been going on, and you made sincere efforts to get insurance reimbursement. Unfortunately, your appeal was denied, probably by a medical review board which typically entails having a doctor and a nurse on board.
Was the lesion at risk to cause problems with your pregnancy?
If it was, it would have (should have) been noted in the records, possibly causing need. However, an addendum now would not look good for you or the dermatologist.
Answer
What is the name of your state?What is the name of your state? Michigan
My insurance provider (Empire BC/BS, based in NY State) has denied payment for removal of a skin lesion, claiming it was not medically necessary because of the diagnosis (seborrheic keratosis; total cost $550). Upon the first denial, I submitted an appeal with a letter from my physician stating that the procedure was necessary to rule out malignancy, as well as medical records as requested by the insurance. It was again denied (same reason) and I was told I could file a second appeal, which I did, with another letter from my physician (more specific, stating that the lesion had changed during my recent pregnancy and was irritated). It was again denied. This time, I was told that because my physician mentioned only that the lesion had changed during pregnancy (not that it had enlarged or changed color) and that it was irritated (but did not specifically mention itching or bleeding) that this did not meet qualifications for medical necessity.
Because it took several months to exhaust both appeals, I have now passed the time limit for applying for an external appeal from the state of NY (45 days from the date of final adverse determination from the first level of appeal). Because I live in MI, I was not aware of this time limit, or I would not have submitted the second appeal! I was not informed of this time limit, nor of my right to an external appeal, by Empire in their correspondence.
I am absolutely certain that this procedure was medically necessary (it may or may not be worth noting that I am a physician myself), but I am not certain how well this was documented in the original procedure note. Can I sue Empire in small claims court? If so, do I do so in NY or Michigan? If I am able to prove medical necessity to the court, is this sufficient?
Thank you so much.
Your insurance company should have sent you a letter with the initial denial explaining your grievance options to appeal in that state. If they did not do this, that is potentially grounds for an insurance commissioner complaint.
Also, insurance companies can no longer deny services in New York without a physician review having been done first of your file. It sounds like this may have occurred from your post, however. It also depends on what state your plan was written out of--you and your doctor may be in Michigan, but the plan may have been written out of a different state and then that state's legals apply.
That being said, it does sound like this was a potentially cosmetic reason to have the lesion removed. And as you stated, perhaps your physician did not document their reasons as well as they could have. However, exhaust all your appeal options with your insurance company. If they have to send the a file out for review 2-3 times it can get very costly and it may be cheaper for them to just bite the bullet and pay it instead of fighting it.