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POEM procedure denied by insurance on pre-approval authorization. What to do next?

Posted , 6 users are following.

pratik20
pratik20

My case is little bit different. I initially was planning to do Heller and i got the approval as well. Few days before surgery after meeting with my doctor, i decided to go for POEM. Doctors office said they sent the necessary documents to their pre-cert department to get the approval for POEM on July 10th. I followed up with the insurance after few days and came to know that surgery date has been updated for Aug 11 but the procedure code was same as for Heller. I became nervous and called doctor office on July 21st and they said my POEM has been approved. I mentioned what my insurance said but they said not to worry about - both procedures are myotomy so insurance might have got confused. I persisted with my doubt and had the pre-cert of my insurance talk with pre-cert of the hospital. They finally had the new code for POEM added to my case on July 28th. I even called my doctor's office asking for the code and at that point the lady flipped. She just hung up saying " I don't know about the code." On July 31st, the pre-cert department of my hospital and my doctor's office were notified that the new procedure code was denied. I haven't heard anything from my hospital and it is august 2nd. I found all this information from my insurance. Now I am really not sure what to do. surgery is still scheduled for 11th and I don't know what the doctor's office is thinking not telling me about this.

Does anyone has any suggestion on what to do if your POEM gets denied in 1st place on pre-authorization request?

2 likes, 6 replies

6 Replies

  • Cowgirluc
    Cowgirluc pratik20

    Posted

    Go with the heller one . I had it dine and I have 5small 1" inchions a 6one in belly button but I had that one open 2xbefore . it nor that bad at all I recovered from my surgery part but have had bad problems with Ibs or the achalsia spreading throughout me. Good luck!

  • Robert13450
    Robert13450 pratik20

    Posted

       First off I would delay your POEM until you are sure it's being paid for. Mine cost $82,000. So you must talk to the insurance company and make them understand what the procedure is and that it needs to be done asap! Sometimes these people that sit behind a desk that can control a part of your life should take another look at themselves. Just get everything solid before moving forward. 

    • Cowgirluc
      Cowgirluc Robert13450

      Posted

      I would go with the Heller rather than the POEM . I asked my doc what's the difference and what's better he said that he doesn't do the POEM cause if failure of people having acid reflux .I do not have any reflux at all. No pains but I do still spaz I got type 3😊

    • pratik20
      pratik20 Cowgirluc

      Posted

      Hi Cowgirluc/Robert,

      I finally had my Heller on Friday. I came home on saturday after few tests and after tolerating clear liquid in the hospital. I couldn't sleep in hospital. One problem I am having is with sleep. Last night at home, I couldn't lay flat on back as i feel my abdomen being stretched. it didn't hurt but was very uncomfortable as my abdomen was stretched. So i slept on couch in upright position surrounded by pillows. Any suggestion for sleep? Today is day 3, 2nd day of clear liquid diet. I think am ok with the diet. Need to figure out about the sleep as I need sleep for better healing

  • teached_1000
    teached_1000 pratik20

    Posted

    what is your current status..  my gf  has the same issue,  denied coverage ,  already had the balloon that was unsuccessful
    • emusedone
      emusedone teached_1000

      Posted

      I’m anxious to hear also. I’m waiting for approval of HM or POEM. I don’t care which at this point, I just need this fixed, I’m so miserable. 
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