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Joined: Jan 2013
Posts: 65
LilyFoo Offline OP
Supporting Member (50+ posts)
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Supporting Member (50+ posts)

Joined: Jan 2013
Posts: 65
My cancer policy is denying my claim for my husband's recent surgery to correct a Tracheostomy defect noted on his last PET scan. His stoma was so small that even a child's size lary tube could not be inserted. Under the surgery benefit the definition of a covered surgery reads "for the purpose of treating a diagnosed cancer." It also has a Prosthesis coverage. Could I claim his stoma as a prosthetic device since it replaces a normal body function?

I think since his stoma was created due to cancer treatment that the correction of the defect is still cancer treatment. It's not from anything else!

Anybody had this fight with an insurance company?

Sheryl


Wife/caregiver to Charles
ENT diagosed SCC Rt Tonsil Stage IV, MET 6 lymph nodes in neck 1/2001
Tonsillectomy, RND and six weeks RADS 2/2001
ENT diagnosis from CT scan, SCC in Rt tongue 2/13
25% of tongue removed 2/13 (clear margins)
SCC BOT with mets to 2 level 2 nodes and Lt. Delphian node 8/2014
Surgical biopsy shows cancer in larynx 9/2014
Laryngectomy, resection & rebuilt tongue w/ pectoral muscle, selective neck dissection 11/2014
Recurrences '16 HPV Neg No EGFR Mutations Detected
Joined: Jun 2007
Posts: 10,507
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Administrator, Director of Patient Support Services
Patient Advocate (old timer, 2000 posts)
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Administrator, Director of Patient Support Services
Patient Advocate (old timer, 2000 posts)

Joined: Jun 2007
Posts: 10,507
Likes: 2
Im sorry you are having to deal with insurance companies on top of everything else. All too often insurance companies will deny claims. The next step is to appeal their decision. If possible include a letter from the physician explaining everything in detail including how its still related to his cancer and its treatment.

From what I remember when I had to battle my insurance company was that with letters from my doctor and a phone call or 2 they eventually approved the claim. I learned to not give in and accept their decision. Even if they make it difficult, keep appealing until you have exhausted all avenues. I had 2 denials until I could get the insurance company to cover my procedure.

Good luck!!!


Christine
SCC 6/15/07 L chk & by L molar both Stag I, age44
2x cispltn-35 IMRT end 9/27/07
-65 lbs in 2 mo, no caregvr
Clear PET 1/08
4/4/08 recur L chk Stag I
surg 4/16/08 clr marg
215 HBO dives
3/09 teeth out, trismus
7/2/09 recur, Stg IV
8/24/09 trach, ND, mandiblctmy
3wks medicly inducd coma
2 mo xtended hospital stay, ICU & burn unit
PICC line IV antibx 8 mo
10/4/10, 2/14/11 reconst surg
OC 3x in 3 years
very happy to be alive smile
Joined: Jan 2013
Posts: 65
LilyFoo Offline OP
Supporting Member (50+ posts)
OP Offline
Supporting Member (50+ posts)

Joined: Jan 2013
Posts: 65
Thank you! I have requested a letter from his surgeon. Sheryl


Wife/caregiver to Charles
ENT diagosed SCC Rt Tonsil Stage IV, MET 6 lymph nodes in neck 1/2001
Tonsillectomy, RND and six weeks RADS 2/2001
ENT diagnosis from CT scan, SCC in Rt tongue 2/13
25% of tongue removed 2/13 (clear margins)
SCC BOT with mets to 2 level 2 nodes and Lt. Delphian node 8/2014
Surgical biopsy shows cancer in larynx 9/2014
Laryngectomy, resection & rebuilt tongue w/ pectoral muscle, selective neck dissection 11/2014
Recurrences '16 HPV Neg No EGFR Mutations Detected
Joined: Jan 2013
Posts: 65
LilyFoo Offline OP
Supporting Member (50+ posts)
OP Offline
Supporting Member (50+ posts)

Joined: Jan 2013
Posts: 65
Instead of writing a letter Charles' surgeon called the insurance company. This morning the insurance company approved the claim! Thank you for encouraging me not to give in.


Wife/caregiver to Charles
ENT diagosed SCC Rt Tonsil Stage IV, MET 6 lymph nodes in neck 1/2001
Tonsillectomy, RND and six weeks RADS 2/2001
ENT diagnosis from CT scan, SCC in Rt tongue 2/13
25% of tongue removed 2/13 (clear margins)
SCC BOT with mets to 2 level 2 nodes and Lt. Delphian node 8/2014
Surgical biopsy shows cancer in larynx 9/2014
Laryngectomy, resection & rebuilt tongue w/ pectoral muscle, selective neck dissection 11/2014
Recurrences '16 HPV Neg No EGFR Mutations Detected

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