A true story...

Shortly before the holidays, I visited my gynecologist. The visit went as such visits usually go: breast and internal exams, PAP smear, conversation about any concerns I might have. Right before it was over, the doc asked if I wanted a mammogram. We chatted about it. I'm 37, and I wasn't sure if my insurance company would pay for it until I was 40 years old. We discussed my family history of cancer, which is quite extensive, and decided to go ahead with it. She wrote the script and I headed to the checkout area. She's part of the local hospital's faculty practice, so her office staff called the scheduling area and made an appointment for me. January 4th.

Between the appointment at my gynecologist's office and my mammogram appointment, my mother died of cancer. One more cancer in a long family history. I was nervous about the appointment, but everything went well. A week or two later, I get the results from my gynecologist - negative. Everything is OK, and now I have a clean baseline to refer to, just in case. Great, right?

A few more weeks go by, and I receive a bill in the mail for the mammogram - $281.00

My insurance denied the claim because I'm under 40. I should have expected this since, like most plans, they do not pay for routine mammograms in women under age 40. But this wasn't routine; it was specially ordered due to my extensive family history. The hospital coded it wrong! My next step is clear: I have to get the code changed to include my family history. I call the hospital billing department. They can't change the code without my doctor's permission. So I call my doctor. This is where things get bad...

The nurse that I speak with says that they can't help me because baseline mammograms are not recommended in women under age 40. "But the doctor and I talked about this. We agreed that my family history placed me at risk and that an early screening was appropriate." Now the bombshell: "Well, I'm looking at your chart right now and Dr So-and-So wrote that she didn't recommend early screening in your case and that the test was ordered at your request."

OK... two things:

First, since when does the patient order the doctor around? I don't recall putting a gun to her head. If she didn't think I needed the test, why did she agree to order it? But that's a topic for another time...

Second, why in the name of all that is right would a doctor - any doctor - write such a thing in someone's chart without making it clear to the patient that she was ordering the test against her better judgment?

The answer to the second question is easy: the doctor was covering herself, just in case the insurance company who employs her - and make no mistake about it, if your doctor is a participating provider, he or she is employed by the insurance company - wouldn't cause trouble for her later.

Bottom line: they wouldn't help me. The nurse felt horrible, but given what the doctor wrote, there was no way that she could go against it and help me.

Like so many other times, I had to help myself.

I contacted the insurance company and explained that my doctor wasn't being helpful; I would be taking on the challenge of the appeal myself. I got a name, extension number, and fax number so that I could contact the right person once I finished my research and wrote the letter.

Next, I began researching early screening. I combed the Internet for credible sources: medical journals, reputable organizations, government guidelines. I tried to anticipate their questions and objections: Why is early screening recommended? Who needs it? How did I fit into these categories?

I collected the data, read through it and highlighted the most dramatic numbers. I categorized the information and wrote the letter, quoting the most respected sources, making sure to clearly outline how I fell into the early screening category, and being as clear and succinct as possible. The final letter:


February 13, 2008

Claim number: 1X23456789 Member ID: XXX123456789
Patient name: Andrea Smith (spouse) Member name: Steven Smith

VIA FACSIMILE: (888) 123-4567
ATTN: Debbie, Medical Review

Dear Debbie:

Further to our conversation on February 8, 2008, I am writing regarding BCBS of South Carolina’s denial of claim number XXX123456789 on February 5, 2008. (Copy attached for your convenient reference)

The basis of this denial was that I do not meet the age criteria under my benefit plan for routine mammography benefits. However, due to my significant family history of breast and other cancers, there was ample reason to start screening early.

My maternal grandmother was diagnosed with breast cancer, and underwent a mastectomy with follow-up chemotherapy. Both my mother and maternal grandmother were diagnosed with cervical cancer in their mid-30s and underwent hysterectomies. Additionally, my father has had several cancers, beginning at age 21, involving the throat, thyroid, base of the tongue, and prostate. My paternal grandmother died of colon cancer. My maternal grandfather died in 1989 of lung cancer. Lung cancer also took my mother’s life just before Christmas 2007.

The American Cancer Society has found that having blood relatives with breast cancer significantly increases the chance of developing breast cancer. Additionally, the National Cancer Institute states the following in their “Genetics of Breast and Ovarian Cancer” Physician’s Data Query (PDQ) Summary:

“In cross-sectional studies of adult populations, 5% to 10% of women have a mother or sister with breast cancer, and about twice as many have either a first-degree relative or a second-degree relative with breast cancer. The risk conferred by a family history of breast cancer has been assessed in both case-control and cohort studies, using volunteer and population-based samples, with generally consistent results” and that “family characteristics that suggest hereditary breast and ovarian cancer predisposition include the following: two or more primary cancers in the same individual. These could be multiple primary cancers of the same type or primary cancer of different types.”

In light of my family history of breast and other cancers, I am requesting a review of this claim.


Sincerely,



No pleading, no emotion, no threats. Just simple, straightforward information from credible, verifiable sources.

On March 4, my phone rang. It was Debbie, informing me that my case had been reviewed, and payment was approved. I owed nothing.

Lessons to take from my experience:

- Don't panic! A first rejection is not necessarily a final rejection.

- Don't wait. Frustration and anger can be powerful fuels. Use the energy to drive yourself. My fury at my gynecologist got the job done - from rejection to approval - in less than a month.

- If you need help, ask for it. Call your doctor's office for advice. If they won't help you, call your insurance company. Find the person who is willing to help you with the process, like Debbie helped me.

- Go for the most credible sources. Don't use your friend as an example. How can the person reading your letter know you're not making it up? Use respected medical journals, medical associations, and - best of all - the insurance company's own guidelines.