Tracy or others...Permedion question
Yesterday, I received a letter from UHC that they were going to honor my request for an external review regarding my appeal. This is what the letter read,if you dont mind looking at it... then my question is at the end....
"We received Gary Viscio's request for an external review of our coverage decision by an independent review company. We utilize independent companies that use the services of physician reviewers. Our company has no financial interest in any of these companies, which provide services to organizations nationwide.
We selected Permedion to perform this review. We will provide the company with all relevant information and notify you in writing of the company's decision within 30 days.
In selecting a physician to review your case, this company will choose one who holds the same medical license as the physician who provided the medical services under review. Before accepting any review assignments, all physician reviewers must agree, in writing, that they will protect patient confidentiality and will not review cases in which they have a financial interest. These protections help ensure that the physician reviewer's decision is (1) objective, (2) based on the customer's benefit contract and the additional information that we and the customer provide to the review company and (3) consistent with evidence-based medical standards."
First of all...anyone have any experience with this process in an appeal, have any dealings with this Permedion, or can comment on whether this looks good for me?
Then...does this sound like a real bariatric surgeon will be the one reviewing? And if so, is this person making a determination on medical necessity eventhough I have an exclusion in my policy? Why does any of this matter if they are just going to say 'No, you have an exclusion?'
I'm not optimistic but am happy that there is still something happening with my case.
Sorry to be so demanding on MY needs, but without coverage, I feel very self centered lately because I spend a lot of hours thinking about this. I do appreciate that, with you guys, I'm not totally alone. I'm just so jealous of those of you who have your health back!
Thanks...
You HAVE to be demanding of your needs, because without pushing, many of these insurance companies would just keep collecting premiums and routinely deny surgery to those who need it. Sometimes I feel obsessed with my quest for surgery, and thinking about it all the time, but when I was pregnant with my children, I thought about them and the pregnancy all the time, without feeling guilty. I think alot of time it is just the motherly instinct in us to put others feelings before our own. Best of Luck!! I pray for your success--keep us posted!!
Theresa
Permedion is an independent review agency that contracts out and does medical reviews.
From their website:
"In simplest terms, that is what Permedion is about... Providing an unbiased perspective through independent medical reviews, measuring outcomes, and improving health care. Permedion helps insurance professionals, medical providers and government agencies such as Medicare and Medicaid provide the appropriate medical care while controlling escalating health care costs."
Dear So Not Skinny,
I have worked with Permedion reviewers who have come to the hospital where I am employed to do Medicaid reviews for medical necessity. I have found that they follow criteria and apply it fairly to each case.
When we appeal adverse decisions to the physician advisors we get good results....meaning they reverse denials and approve them. This might be a good thing for you. I wish you the best with this. Good luck !
Wow, Sandra, I actually feel hopeful for the first time since starting this. Thank you for responding and sharing your experience. Can you tell me how this might play out given that I am dealing with an exclusion? I am hoping you will say that they look at the needs of the patient and look at medical necessity in spite of an exclusion. Thank you again for your insight.
In my experience, I have never seen a case go as far as an external review when a policy exclusion is present. So, unfortunately, I can't say whether this is a good thing or bad thing....because I just don't know. Well, actually, let me correct myself---this is a good thing b/c it has given you hope. Hope, for however long it lasts and whatever the outcome...is such a blessing to have.
Best of luck and keep me posted!
Tracy Burch
Insurance Coordinator
Dr. Trace Curry's Office
513-559-2544
In my experience Permedion is only going to look at this from the perspective of medical necessity. They will not address the exclusion issue.
Let me give you an example. Most insurance companies will not cover cosmetic surgery and most will list something like septoplasty as an exclusion citing it as cosmetic. A septoplasty is when a nasal septum is surgically straightened. Insurance will argue that the patient wants his nose straightened so they will look better. So insurance denies the request. We appeal that decision to the second level because it usually goes to outside reviewers. If we present evidence of chronic sinus infections or how this contributes to sleep apnea then the review agency will say, "hey this is not cosmetic this is medically necessary" and their decision will reverse the denial.
I think this is good for your case because it has taken it out of the hands of the insurance company doctors who are in the back hip pocket of the insurance company. I do not not have experience with bariatric cases but I see where your attorney is headed with this.
Now let me tell what else this might do for you. If they say that you meet medical necessity and insurance still bucks ....then you have grounds to file a grievance which is different from an appeal.
This will be very interesting to see how this plays out. Keep us posted.
I was referencing to only bariatric cases, as that is where a vast amount of my knowledge is. Actually, what I have seen is insurance companies that won't approve an external review if an exclusion is present. Obviously, this is not the case for you, as you are able to have an external review-even with an exclusion.
Good luck!
Tracy Burch
This is the closest I've felt so far to anything MAYBE coming through for me. I did call Premedion today and asked them if they could tell me what documentation they'd received from UHC...I'm a little worried they might not send everything to the reviewers. As it turns out, they didnt send my referral/recommendation for surgery from my oncologist. They also didnt have a letter from my PCP...turns out I never noticed that my PCP only sent doctor's notes and never really sent his letter. I called my PCP and they dont have a letter, so it seems that UHC has never had that from the beginning. He is writing it today and will fax it over to Premedion who said they'll be making a decision early next week. Whew! I am nervous!
Well, I got denied again...based on medical necessity, I dont qualify because I have "no life-threatening co-morbities", I guess. I have GERD, sleep apnea, fatty liver, hiatal hernia, lymphedema, arthritis in my back and hip, depression, strong family history of heart disease and diabetes and cancer, family history of obesity, and am a cancer survivor of a rare, aggressive type of breast cancer that has a very high incidence of reocurrance. Being obese increases my chance of that happening significantly. I have a call in for my attorney (Gary Viscio) to see if I am at the end of my rope with appeals here. I am sooo mad! Are none of these comorbidities? And this was the outside agency that did indeed evaluate my case for "medical necessity" rather than considering that I have an exclusion. The denial letter they sent said that their decision was based on the fact that my BMI at 37.5 did not have any lifethreatening comorbities and that surgery would not prolong my life. What is WRONG with these doctors???!!! I hope they all get really FAT! (I dont mean that).
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