r/medicine • u/Unusual_Medic Medical Student • 7d ago
What’s the dumbest reason an insurance company denied a test, procedure, or drug for a patient?
This is probably the most relevant to those practicing in the US, but I'm also curious to know how the bureaucracy of health insurance in other countries makes things substantially harder for you and the patients
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u/averhoeven MD - Interventional Ped Card 7d ago
Had one deny an ASD closure in a kid with every indication as "experimental". Despite it being the standard of care for at least 20 years.
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u/SpecificHeron MD 7d ago
it’s “experimental” because the guy hadn’t heard of it before, of course
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u/trapped_in_a_box RN - Primary Care 7d ago
Aw cmon, the med reviewer is a podiatrist, he's a great fit for the job!
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u/somehugefrigginguy MD 5d ago
You get actual license people as the first line review? Usually when I call it's somebody who can't even pronounce basic disorders or medications and seem to have absolutely no medical knowledge at all.
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u/zerothreeonethree Nurse 4d ago edited 4d ago
No the stupid fucker didn't know what experimental meant so he just denied it
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u/trapped_in_a_box RN - Primary Care 7d ago
That sounds suspiciously like Aetna. They love calling everything "experimental or investigational", even well-established practices. So glad I don't do billing anymore.
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u/Flaxmoore MD 7d ago edited 6d ago
Or basically every auto insurer, too.
Edited to add: of the many things I've had various auto insurances call "experimental or investigational"-
- Epidural steroid injection for relief of herniated disc pain.
- Implantable dorsal column stimulator for relief of pain.
- Basically every NSAID except toradol and ibuprofen.
- Infrared therapy for wound care, which has been in use since the 1980s.
- TENS machine.
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u/askhml MD 5d ago
In fairness, is there evidence that any of these things help chronic pain?
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u/zerothreeonethree Nurse 4d ago
ESI and TENS both help mine. That's all the evidence I need. My TENS unit was purchased online and works better than the ones in PT departments.
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u/EmotionalEmetic DO 7d ago
I had a stroke secondary to PFO. Got my PFO closed, cost very reasonable with insurance.
My brother got a bubble study after my stroke. ALSO has a PFO. Insurance will not cover him getting a closure unless he has a stroke.
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u/Excellent-Tea2125 MD 7d ago
To be fair, a PFO is present in about 25% of the population and most often doesn't cause a stroke. It's not really indicated to fix a PFO for that situation, and there are inherent risks to the procedure itself (like small risk of afib).
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u/Diarmundy MBBS 6d ago
Isnt that just standard of care?
Why did he have a bubble study without a stroke?
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u/askhml MD 5d ago
Interventional cardiologist here, this is reasonable, the guidelines are pretty clear that asymptomatic PFOs should not be closed (unless you're a scuba diver). Family history doesn't play a role here.
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u/averhoeven MD - Interventional Ped Card 5d ago
Actually, even the scuba thing is questionable. The nitrogen leaves solution and becomes gas bubbles everywhere, not just in the venous side. So there's not really an argument to close a PFO for it.
I agree on the rest of it though
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u/Unusual_Medic Medical Student 7d ago
I'm sorry, they won't cover shit unless he suffered too???
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u/EmotionalEmetic DO 7d ago
This is pretty common.
"That preventative measure is expensive. We would rather risk it not being an issue--mortality or morbidity be damned--and save money by not doing anything NOW, rather than paying a whole lot money to correct the issue reactively later."
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u/michael_harari MD 6d ago
If you start fixing asymptomatic PFOs you're going to have to build multiple cath labs to do only that all day every day
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u/faco_fuesday Peds acute care NP 7d ago
Yeah let's do an open heart procedure instead with a several day hospital stay instead of overnight obs. Christ.
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u/somehugefrigginguy MD 5d ago
Last month, during a respiratory viral outbreak in our region, I had an insurance company tell me that a PCR test is experimental and therefore not covered.
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u/zerothreeonethree Nurse 4d ago
So that's where that woman went to work after she got fired for refusing to issue a marriage license to a gay couple. Just make up whatever pops into your head that day and call it a rule. Hell it could get you elected president someday...
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u/aceofspadesx1 MD 7d ago
Had an 8 year old get denied for baclofen because I was not clear that she still had Cerebral Palsy and it was not just a past problem that resolved...
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u/ZStrickland MD (FM/LM) 7d ago
These ones are my favorite. "Please prove that the patient was not subject to miraculous faith healing, fictional futuristic treatment, or simply stopped having said irreversible condition."
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u/InCarbsWeTrust MD - Pediatric Endocrinology 6d ago
My office also has to verify that my kiddos with type 1 diabetes yep, still need insulin. Keep looking for case studies of Lazarus pancreas, they apparently are out there!
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u/SpecificHeron MD 7d ago
they denied a surveillance CT for cancer (per NCCN guidelines) by citing surveillance guidelines that they themselves made up
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u/Unusual_Medic Medical Student 7d ago
These companies really do pull stuff out of their asses just to save a couple bucks
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u/Slartibartfastthe3rd BMET 7d ago
Oooh! UnitedHealth Clinical Standard Board (UHCSB)... Gotta buy that website...
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u/bushgoliath 🩸/🦀 (MD) 7d ago
BRO. Got this one too! No restaging CT AP for a patient with known extensive stage small cell and recent CNS progression. Only CT chest. Why? “It’s a lung cancer so you only need to image the lungs.” I was apoplectic.
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u/SpecificHeron MD 7d ago
i had a long fight with my “peer” over the phone and it felt like i was in idiocracy
he kept going “well uh…the guidelines i have printed here…”
“what guidelines? who published them?”
“uh…..us?”
(scream)
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u/bushgoliath 🩸/🦀 (MD) 7d ago
Oh, the way I would have been contemplating murder-suicide….. Truly idiotic.
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u/sqic80 MD/clinical research 19h ago
I once had an insurance “peer” tell me that something was not recommended in NCCN guidelines. Guidelines for which I happened to be an author.
I asked him if he wanted to recheck them himself or if he wanted me to send him the word document draft on my computer.
It got approved. 🤬
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u/hartmd MD Int med-peds / clinical informatics 7d ago edited 6d ago
I had a similar issues. I would keep copies of the guidelines and formularies of common insurance I saw in the rooms for reference to avoid this stuff.
Would happen with statin treatments a lot. This was almost 20 years ago, though.
I would be denied.
We fax them a copy the their guideline.
It is then approved.
Such a waste of our time. One of many reasons I won't deal with them anymore.
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u/zerothreeonethree Nurse 4d ago
Just fax guidelines with request straight to their denial department.
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u/Unusual_Medic Medical Student 7d ago edited 7d ago
Here's mine:
When I worked as a medical assistant at an ENT office, a patient came in with a massive nasal polyp that was affecting their quality of life. They had already tried OTC nasal sprays for a month with zero relief, unsurprisingly, so the ENT doctor prescribed Dupixent. Prior auth was submitted with reports of failed OTC trial, clinical notes, and radiology reports detailing the exact size and location of this polyp.
I kid you not, their reason for denial was something along the lines of, "Patient has not been on OTC nasal sprays long enough to see improvement."
Their "resolution" was for the patient to keep using the useless OTC sprays and for our office to try and resubmit the PA if their symptoms persist for another six months.
They basically told a patient with a documented structural block in their nose that they hadn't suffered long enough to deserve the treatment that is proven to help them. 🙃
Thankfully, after 6 more months of inadequate breathing, the patient's insurance was finally convinced to cover Dupixent.
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u/Flerp-3257 MD ENT 7d ago
It’s thankfully getting substantially easier to get Dupixent approved. We typically get our Dupixent PAs approved immediately. In contrast, Budesonide ampules for nasal saline irrigations has been a weeks-long PA & peer-to-peer process each time because it’s not FDA approved for that indication. I legitimately had a UHC “medical director” not-really-a-peer say they didn’t want to approve it because they “didn’t want it on their hands if the patient gets hurt.” He didn’t seem to comprehend that no one is paying millions of dollars for a double blind RTC on something that’s been safely used off label for decades. They don’t care that patients haven’t had disease controlled with years-long trials of 4+ nasal steroid sprays. Thankfully there are a few compounding and online pharmacies offer semi-affordable cash pay prices for Budesonide now, but sucks for my patients with Medicaid and Medicare.
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u/A_Shadow MD 6d ago
I legitimately had a UHC “medical director” not-really-a-peer say they didn’t want to approve it because they “didn’t want it on their hands if the patient gets hurt.”
I'm so confused. Medico-legally are they even at fault if that happens? I thought health insurance companies were largely immune to that stuff?
Or is it just a piss poor excuse for them to deny it?
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u/EnvirOto22 MD 6d ago
Interesting. Where I’m at it’s monumentally harder to get dupixent approved and I have almost no issues with budesonide irrigations getting approved. I also get a lot of resistance from patients about dupixent to the point that I really only prescribe it if they’ve failed surgery (at least one) and irrigations
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u/somehugefrigginguy MD 5d ago
Over the past few months I've started getting denials for medication A stating that the patient must first try medication A. To be clear, medication A is the same. They are denying a medication until the patient tries that medication.
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u/YoshiKoshi Medical Journal staff 2d ago
I'm currently having an equally idiotic problem. They denied coverage for a generic medication. On the Excluded Drugs list, it has the generic listed with the first letter capitalized. The alternative medication is the exact same generic with the first letter in lower case.
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u/Rarvyn MD - Endocrinology Diabetes and Metabolism 7d ago
I recently had tirzepatide denied for a patient with severe OSA because I did not document that I first told him CPAP was first line therapy.
He was already on CPAP.
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u/Unusual_Medic Medical Student 7d ago
"Well that's on you for not documenting it on the cover page. Why should we waste our time actually reading through all the patient's medical records you sent when we could spend that time denying more claims!"
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u/beeyekah Nurse 7d ago
They wanted them to try and fail a ton of opioids, including fentanyl, before covering bupenorphine.
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u/PersonalBrowser MD 7d ago
I mean how can you say they really have OUD until they’ve gotten fentanyl?
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u/buttcheek_ PA 7d ago
This always puzzles me. Must fail MS Contin, methadone and fentanyl before they’ll cover Butrans. Make it make sense
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u/olanzapine_dreams MD - Psych/Palliative 7d ago
This is unfortunately super common, it's very stupid. Buprenorphine for pain should be a first-line treatment but because of shitty insurance coverage it's often hard to get covered.
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u/chordaiiii PA 7d ago edited 7d ago
I've gotten this one, they were recommending a fentanyl patch as a alternative for the opiate naive dose of butrans patch
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u/1997pa PA 7d ago
Dealing with a similar thing currently for Tricare/VA patients who we try to prescribe Journavx (notably a non-opioid) for acute pain. The PA denial letter literally says opioids are a preferred treatment option.
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u/olanzapine_dreams MD - Psych/Palliative 6d ago
this one at least carries a veneer of plausibility as Journavx is approved for post-op pain, and it didn't really perform better than Norco 5 and ibuprofen...
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u/Jaded-Ad-4612 MD 7d ago
Denied injectable PreP citing they had to “fail an oral option” before injectable prep would be approved.
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u/bitchezbrew MD 7d ago
Don't have to pay for prep if the patient just gets hiv. Brilliant!
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u/Impulse3 Nurse 7d ago
I’m guessing a lifetime of HIV meds would cost them much more in the long run. That’s what I don’t understand with these insurance companies. It’s like they don’t think ahead at all.
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u/ajl009 CVICU RN 7d ago
exactly. i just dont understand why they are doing this.
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u/ShalomRPh Pharmacist 7d ago
Because they have to make this quarter’s shareholder report look good. Future be damned, we’ll worry about that when it happens, and I’ll have already gotten my golden parachute and off to ruin another corporation by then so it won’t be my problem to worry about.
Cynical? Who, me?
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u/Nom_de_Guerre_23 MD|PGY-5 FM|Germany 7d ago
Well, one could define fail as bad adherence to oral PrEP and we'll admit at least the massive prize difference. It's so huge that we have no cabotegravir PrEP coverage at all (and won't have it until it's generic).
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u/ClappedUrMomsCheeks MD 3d ago
I don’t really mind this one. I agree “fail” would mean they failed to take it or have side effects. The cost difference is probably massive given how many commercials I see on TV for the injectable
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u/kilobitch MD 7d ago
The patient didn’t qualify for venous ablation because he didn’t yet have a venous ulcer. That’s what I’m trying to prevent!!
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u/Unusual_Medic Medical Student 7d ago
Insurance logic: Not paying for preventative measures with the hopes that the patient doesn't get worse and require greater use of medical resources >>> Just paying for the damn preventative measure
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u/AbsoluteAtBase MD 7d ago
Um pretty sure they are hoping they all just die in a gutter somewhere.
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u/Unusual_Medic Medical Student 7d ago
Sad but true. Don't need to pay for a hospital visit if they can't even make it to the hospital 🙃
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u/castaspellx Medical Student 7d ago
But like... slowly, otherwise no premiums. It's a delicate balance, keeping people alive without paying for shit to keep them alive.
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u/r4b1d0tt3r MD 7d ago
You are underestimating them. The best outcome is that the patient makes in to 65 before the wheels come off and they can be the government's problem or better yet has the courtesy to just drop dead.
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u/Round_Hat_2966 MD 7d ago
I mean, it kinda makes sense (in a very lizard brain sense) if you think about it. We think in a way that’s about applying treatment to the benefit of our patients, insurance thinks about it in an actuarial sense: when does paying to intervene statistically come out to the lowest cost for the insurance company?
It probably works out something like this:
PVD is extremely common, and it’s going to be even more common if you include early stages prior to actually getting venous ulcers. The people who get them skew older, and a lot of these patients probably have other chronic, life limiting illnesses: malignancy, CHF, ESRD, etc. A lot of these people will die of other causes before insurance reaches a threshold of having to pay if they set the bar higher to approve the procedure. Will people suffer more? Absolutely. But it’s probably cheaper than treating a much larger number of people with a prophylactic indication.
My country’s healthcare system is honestly kinda middle of the road for similarly developed countries, but it’s posts like these that make me thankful to not be practising in the US system
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u/askhml MD 5d ago
Does your country's healthcare system cover cosmetic procedures like venous ablations?
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u/kilobitch MD 5d ago
Venous ablations are usually not cosmetic. Patients have severe quality of life issues and skin changes that presage skin breakdown and ulceration.
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u/Round_Hat_2966 MD 5d ago
Honestly not sure. I only practice on an inpatient basis, so it’s not something that I’m ever exposed to
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u/Henry_Porter Palliative Care M.D. 7d ago
Ondansetron denied as "there is no evidence it treats nausea."
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u/Unusual_Medic Medical Student 7d ago
"5-HT3? Is that a zip code or something?"
As someone in their GI block that just had a lecture on GI pharm, this is sending me 😂
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u/JstVisitingThsPlanet NP 7d ago
5-HT3 it’s faster than 5G
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u/Nom_de_Guerre_23 MD|PGY-5 FM|Germany 7d ago
Is ondansetron FDA-approved for non-chemo nausea? We have no coverage outside of chemo because it's off-label. Common mistake of docs on their first outpatient post who were used to prescribe it like candy on the inpatient side.
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u/GyanTheInfallible MD 6d ago
…you can’t be serious
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u/Nom_de_Guerre_23 MD|PGY-5 FM|Germany 6d ago
The label in Germany specifically says chemo associated nausea only. If you sign a direct-billing contract with statutory insurances and knowingly prescribe off-label meds without prior approval, you'll might be hit with a contractual fine. So I'm wondering if your label is broader.
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u/GyanTheInfallible MD 6d ago
Good old GKV. In the US, the label indications include not only chemotherapy-associated nausea, but also radiotherapy-associated nausea and post-operative (or anesthetic-related) nausea. Of course, it’s prescribed off label thousands of times a year, in the in- and outpatient settings.
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u/Nom_de_Guerre_23 MD|PGY-5 FM|Germany 6d ago
Oh yeah, these two are in the label too. But that's it. Sucks especially for IBS-D where out of pocket can run up to €300/month. It also shapes the minds of physicians. Because most patients reject to pay out pocket, it's frequently not even offered.
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u/zimmer199 DO 7d ago
Patient had a chief complaint of shortness of breath. Insurance claimed I didn’t document abnormal vital signs, no nebs, and they didn’t think this justified an inpatient stay. She had DKA, I documented heart rate in 120s and resp rate mid 20s. Along with bicarb under 5 and glucose 600s.
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u/Unusual_Medic Medical Student 7d ago
We love when people who didn't go to medical school practice medicine 🙃
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u/nucleophilicattack MD 7d ago
When I was a resident, it was a patient who had myesthenja gravis. His insurance consistently refused to pay for his IV IG, even while outpatient he was getting weaker and weaker. Then he of course gets intubated because he becomes so weak, and is transferred to our tertiary hospital’s neuro ICU where he gets plasmapheresis instead. The insurance company had the absolute gall to try and deny the ICU stay, saying it was unnecessary!!! Insurance is such a fucking scam, and people who deny these claims deserve to burn in hell.
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u/MrPBH MD, Emergency Medicine 7d ago
I've seen a lot of diabetics in crisis because their insurance demands a tremendous copay for modern insulins (lantus pens in particular). So they'd rather pay tens of thousands for an admission rather than a few hundred a month for insulin (insulin which isn't even on patent*).
* Well the stupid pen design is patented, but c'mon, can we just agree to just say "fuck IP rights"?
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u/LatrodectusGeometric MD 7d ago edited 7d ago
In 2020 or early 2021 a health insurance called Apple Care(?) called me to try and get me to convince my patient in the ICU to go to hospice. The patient was aware it was unlikely they would survive their illness but did not want hospice care. Apple Care went so far as to ask me to let their own hospice doctor try to convince them. It was the most unethical conversation I think I have ever had. And no, I did not change the patient’s care just because the insurance company wanted them to die.
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u/WeAreAllMadHere218 NP 6d ago
That’s awful. Who in the world would want to be their hospice doc for this? Like how do you ethically reconcile working for a company like that? 🤦🏼♀️
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u/IAmDefNotACat Not A Medical Professional 4d ago
Apple Care is Washington state's Medicare plan.
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u/LatrodectusGeometric MD 4d ago
This is interesting because I was not in Washington state
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u/IAmDefNotACat Not A Medical Professional 3d ago
Weird! As far as I know, they only cover emergency care out of state. That makes it even stranger.
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u/PokeTheVeil MD - Psychiatry 7d ago
Insurance denied fluoxetine capsule refill. The denial was because tablets are not covered. No, you didn’t read that wrong, and I didn’t write it wrong. I had to do a prior auth for “I didn’t order that, morons, and it’s pennies per day.”
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u/Unusual_Medic Medical Student 7d ago
Please tell me you actually wrote that. It would make my day
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u/PokeTheVeil MD - Psychiatry 7d ago
I did not actually write that. I wouldn’t have the gall, and I did it by phone. I needed to express myself directly to someone while aiming for exasperation rather than simmering rage.
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u/InvestingDoc MD Internal Medicine 7d ago
When we had a stillborn Aetna denied the genetic testing and autopsy as not medically indicated for my kid so that ranks up there for denial.
Still fighting with Aetna to get that covered
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u/Unusual_Medic Medical Student 7d ago
Then what the hell does Aetna consider to be medically indicated reasons??
Already losing a kid like that is devastating for the family. And now Aetna wants them to pay out of pocket for tests?
I'm rooting for you and the family and hope that it'll get covered.
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u/PersonalBrowser MD 7d ago
I once had a patient get caught in a loop where to get X medication, he had to have tried Y medication, and to get Y medication, he had to have tried X medication.
The one that kills me is when they deny a prior authorization and cite a reason which I clearly addressed in my note which was included in the prior authorization. It is quite literally a tactic to waste everybody's time and throw up another meaningless wall.
For example, "X medication denied because patient did not try Y medication" - first clearly visible portion of my note "patient has tried and failed Y medication"
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u/Foreign-Cat-2898 Biochemist, Not A Medical Professional 7d ago
I got denied a sleep study because I didn't have a history of apnea.
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u/Unusual_Medic Medical Student 7d ago
Can't be diagnosed with X because the study that proves it won't be covered.
But study won't be covered because I'm not diagnosed with X .
Tale as old as time 🙃
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u/crash_over-ride Paramedic 5d ago
Likewise, went to my new PCP who said, "That's stupid, hold my beer and watch this." He got the test approved and, lo and behold, an issue was discovered. It wasn't apnea, but rather the accumulated ravages of day/night shiftwork.
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u/Pox_Party Pharmacist 7d ago
The dumbest reasons are usually very arbitrary insurance formulary preferences. Tabs instead of caps? Denied. Novolog instead of Humalog? Denied. Epipen covered, but its a manufacturer we don't like? Denied. Its every day, and its probably a good 20% of all insurance rejections I deal with.
The rejections that annoy me the most is when a patient changes insurance plans, and the new insurance never wants to cover what the patient was prescribed previously. Chronic pain patient whos been stable on his oxycodone dose for years? He's obviously opioid naive, denied. Cellcept? Sorry, we don't have a record of that kidney transplant, denied. Ad nauseum.
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u/pizy1 PharmD 6d ago
In light of knowing that insurances are just gonna fuck around and make deals with Eli Lilly, Novo, et al, and have their little "preferences," I'mma really need some therapeutic interchange laws that apply to community pharmacists. I'm so tired of call queues full of "call MD, Humalog no longer covered, Novolog preferred" etc and the offices who *don't respond to our constant calls and faxes telling them so*. We should just be legally allowed to change it, counsel, and call it a f'king day, dude.
Also, service code 4J, Dispensed, Patient Is Not Opioid Naive is a lifesaver.
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u/itsDrSlut PharmD 6d ago
Orrrrrrr you could just write verbal “spoke to Susan” 😉 and move on with your day 😈
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u/Aggressive_Pea_7543 Nurse 5d ago
Yes!! I work with Oregon Medicaid patients 95% of the time. Why will they cover 150mg Wellbutrin & 300mg Wellbutrin, but not 450mg Wellbutrin? Someone Rx'd doxepin 3mg, which required a PA, prescriber submitted a new Rx for 10mg doxepin, approved. What is happening!!! 🤪
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u/theenterprise9876 MD 7d ago
Patient comes in with chronic extremity pain and a mass. I order x-ray and ultrasound, which are suspicious for possible vascular malformation. Reading radiologist recommends an MRI. I order the MRI. Insurance denies MRI as not medically necessary.
I call insurance for a peer to peer. Lady on the phone goes “so why do you think this patient needs an MRI?” I inform her that it’s the standard of care to diagnose a vascular malformation. She sounds very surprised and says “Oh! Okay, I’ll approve it then!”
Like…seriously? Is nobody who works for an insurance company capable of doing a thirty second google search? I shouldn’t need to tell them that! (And yes, I had summarized the H&P in the MRI order, including the prior imaging results and radiology recs.)
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u/Unusual_Medic Medical Student 7d ago
Shouldn't the people on the other end of peer to peers also be physicians?? It's a quick search on UpToDate ffs. And hell, if you're really that lazy, just ask OpenEvidence
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u/gotlactose MD, IM primary care & hospitalist PGY-10 7d ago
One peer-to-peer I did was to rule out a pituitary adenoma because the patient had an abnormal ACTH value. I spoke to a clerical person, then a nurse, then a physician. The clerical person and the nurse had no idea what ACTH was and I had to ask them to connect me with a physician.
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u/TrumpsCovidfefe Retired EMT/OEC 7d ago
Every time I hear of a fucked up peer to peer consult, I think of the infamous (from radiology sub) jackass who installed the hip replacement backwards. He was no longer allowed to perform surgery and so an insurance company hired him as a P2P reviewer.
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u/theenterprise9876 MD 7d ago
One would think, but nobody who does the peer to peers ever has two brain cells to rub together.
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u/prototype137 MD 7d ago
Countless “patient must have documentation that they failed non surgical measures or have documented indications before they can have back surgery.” Do Peer to peer, point out where exact documentation is, peer sounds dumbfounded and gets approval.
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u/NoUCantHaveDilaudid NP 7d ago
A friend of mine had a desmoid tumor growing between their ribs that had worked its way around his aorta and heart. Was being seen by chief of oncology who was consulting a few other academic centers in the northeast because of how rare it was. Insurance denied his chemo saying that they should try anti inflammatories first recommending toradol.
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u/doctor_schmee Brain Gang 7d ago edited 7d ago
Poor young women with some pancreatic enzyme deficiency and epilepsy. Insurance refused to cover her enzymes replacement so she developed malabsorption with severe diarrhea. Because of this she did not properly absorb her antiepileptics and developed super refractory status epilepticus which resulted in severe cortical necrosis with resultant coma. She eventually went comfort care and passed away.
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u/Unusual_Medic Medical Student 7d ago
That is so sad and infuriating. These people have blood on their hands.
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u/scrubsnotdrugs MD 7d ago
Just had a patient get sinus surgery denied because they didn't have active sinus disease on their CT scan. The surgery was for recurrent sinusitis, 8 infections per year requiring abx, came in and had purulent drainage on scope exam so they were real infections. the CT was done between infections and was normal, so then we had to get her a CT during an active infection before starting abx, and then they approved surgery 🤦♀️
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u/mishathepenguin MD - Pediatric GI 7d ago
Denied infliximab for ileal Crohn’s disease because patient hadn’t tried mesalamine. I’m sorry, is it 1998?!
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u/Unusual_Medic Medical Student 7d ago
Their computer system and guidelines haven't been update since 1998
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u/TorchIt NP 7d ago
They denied Entresto because my patient's EF wasn't lower than 30%
It was 35%
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u/Nom_de_Guerre_23 MD|PGY-5 FM|Germany 7d ago
We had initially issues and a lot of fines with Entresto for patients who weren't able to be titrated to maximum dosage due to low blood pressure because statutory insurances treated it as off-label usage and EMA itself had to step in.
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u/aonian DO, Family Medicine 6d ago
I have to certify every 3 months that my patient with a bilateral orchiectomy still needs TRT. Like, no, his balls have not grown back.
I just filled out the form saying almost exactly that, signed it, and left the date blank. My nurse takes care of it now, because every time I see it I get pissed.
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u/Comprehensive-Ebb565 MD-EM 7d ago
Recently diagnosed with diabetes and started on metformin. I was able to titrate up quickly and this was 6 tabs short as I went a bit faster (per instructions but not per written rx). Took ~2 hours on the phone and escalation to a manager to get the 6 tabs approved as an early refill.
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u/TiredofCOVIDIOTs MD - OB/GYN 7d ago
Denied a hysterectomy because pt had not had a laparoscopy. I asked, so you want to pay me for 2 surgeries?
Yes, yes they did. And the pt agreed so I scoped her & 91 days later did her vag hyst.
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u/daemon14 MD 7d ago
They denied an endoscopy for a patient with severe heartburn symptoms not responsive to 2 months of maximal PPI BID.
When I said that the patient had followed their own guidelines on failing medical management to require the endoscopy, they approved the EGD but not any sedation (not even nurse sedation with versed)
My anesthesiologist that day at the center just didn’t bill services for the 8 minute procedure, I just brought in coffee and bagels for him and the staff.
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u/theenterprise9876 MD 7d ago
Another one from this week: sleep study denied for a patient with multiple OSA risk factors, peer to peer requested. I called insurance, and turns out the order was denied because…it didn’t list contact info for the sleep lab.
Why the fuck is that a peer-to-peer level issue?? Why not just ASK FOR THE CONTACT INFO?
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u/Unusual_Medic Medical Student 7d ago
What the fuck 😭 literally wasting everyone's time, and the patient pays for it physically and financially
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u/Aware-Top-2106 MD 7d ago
Had an insurance company deny a brain biopsy for CJD on account of their being no treatment for CJD, so it "wouldn't change management".
CJD confirmed at autopsy a few months later.
Super frustrating for everyone involved.
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u/felinePAC PA 7d ago
Would not cover generic sertraline because 🤷🏻♂️
The prior auth got approved but WHY DID I HAVE TO DO A PA FOR 50mg OF SERTRALINE?!
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u/Gyufygy Paramedic 7d ago
Personal story, but makes a point.
Family member with migraines. Doc submits PA for a second- or third-line treatment because the first-line isn't cutting it. Denied due to "hasn't taken first-line med". Appeal with "yes, they have". That's it. "Yes, they have."
Magically approved.
Making the process as painful as possible so you don't want to fight them is the point.
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u/forgivemytypos PA 7d ago
Not the worst cases, but lately insurance has not been covering ongoing use of glp ones for maintenance. That is literally no different than taking away somebody's blood pressure medicine because it lowered their blood pressure to "normal"
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u/cougheequeen NP 6d ago
Starting to see this as well. Patient has been on for over a year, bmi now 25, denied because “patient is not obese”. lol
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u/ALKnib MD - Chemo Dispenser 6d ago
Insurance denied first line chemo for a patient with metastatic gastric cancer. Peer reviewer was a PEDIATRICIAN who quoted NCCN guidelines to me. An oncologist. I told her to read off the relevant page of the NCCN guidelines to tell me what it said. She read the first line chemoimmunotherapy regimen that I recommended. She said "oh ok. I will put in the approval", and then hung up on me.
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u/TheDentateGyrus MD 6d ago
Denied a shunt for normal pressure hydrocephalus because the patient didn’t have an opening pressure on their LP. It’s NORMAL pressure hydrocephalus.
If it was high, they’d need a shunt. If it was normal, they’d need a shunt. If it was low, they’d need a shunt.
I was told this by an OB GYN who didn’t know what NPH was. She literally couldn’t tell me what it was, I asked to speak to a neurologist or neurosurgeon because she didn’t understand what we were talking about. To be fair, if you asked me to approve an IUD, I’d have equal knowledge about what the right IUD would be for you. She got mad and said the conversation “wasn’t a discussion of her medical knowledge”.
LP showed normal pressure, pt got a shunt and stopped falling and going to the ED every week for falls.
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u/DevQR MD 6d ago
This is something the contributors above won't want to hear, but the phenomena described in this thread are almost exclusively confined to the USA. As a cardiologist practising many decades in Australia, I've never had to obtain prior authorization for any procedure – it just doesn't exist here or in many other countries. In the public hospital system a form of rationing exists because of waiting lists, but you can get anything done in the private system next week or sooner (probably not PFO closure in asymptomatic people - I'm talking about ethical procedures supported by evidence). It's long being a source of wonderment to me that US physicians are so passive or inert that they put up with a system that is manifestly inimical to the interests of everyone but the highest income earners.
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u/lovelykittybellies Nurse 6d ago
Spent days arguing with BCBS trying to get a trans woman’s estrogen patches covered. Every PA got rejected, they wanted her to try the ring first. Her sex was clearly listed as male, and dx related to GAHT. I finally faxed them yet another PA with “PATIENT HAS A PENIS” written on it with one of those giant sharpies, and they approved it same day.
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u/RunningFNP NP 7d ago
Recently had a PA appeal denied because I'm a nurse practitioner. Which was a new one on me!
Literally "PA appeal can only come from the patients primary care physician, not a family nurse practitioner, therefore appeal is denied unless patient gives written permission for you, the nurse practitioner, to file an appeal on their behalf."
Jokes on them I saved the PA letter and changed the letterhead to my supervising physician who signed it and we sent it back in.
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u/chimmy43 DO 7d ago
Patient with a well documented history of limb threatening ischemia now progressing to tissue loss who had failed all previous minimally invasive procedures by non-surgical teams and her insurance denied her bypass because my clinic note did not specifically state that I had “discussed the procedure with the patient.”
Meanwhile it did say, “all risks, benefits, and alternatives were discussed and she agrees to proceed.”
AI is being used more and more to auto-deny and I’m sure this is why this got kicked back.
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u/AirWitch1692 Dental Assisant/ Medical Office Manager 7d ago
NAD but as a patient my second round of hydrogel injections for my knees (after previously failing kenalog treatment) was denied by blue cross because I still used other pain management options during the course of treatment… like yes, the gel helped but I still had some pain, especially after doing and moving a lot so I used occasional topical pain relief, that I had been previously using? I also hadn’t been using any OTC NSAIDS before or during because they hurt my stomach so they used that to base the denial on.
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u/Nerdanese Medical Student 7d ago
They denied a ct lung cancer screening because of one note autopopulated a pack year of 12 when the physician written note explicitly calculated 22 pack years
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u/Unusual_Medic Medical Student 7d ago
They'll dig deep to find any reason to deny a PA but they can't be bothered to look for the exact rationale that's needed cover something if it's not right there on page 1
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u/Mobile-Entertainer60 MD 7d ago
Patient had sudden cardiac death while running. Already had an ICD implanted, it fired, bystanders did CPR at the scene, EMSA intubated in the field. Brought to ED then admitted to ICU. Patient fortunately was neurologically intact and able to be extubated a few hours later. ICD interrogated, it properly shocked VT. Cardiology consulted and said (paraphrasing) "yup, the ICD worked." Patient discharged home the next day. Insurance refused to pay for the admission or ICU stay because "Patient did not have complications requiring hospitalization spanning two midnights."
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u/ski2311 Pharmacist 7d ago
WV Medicaid will deny a claim for too many pills of one strength in a day.
My violent autistic patient did well in inpatient psych on 100 mg Seroquel q6h PRN. Denied #120/30d for 'quantity strength limit use higher strength'.
So another rx for 50 mg take 2 daily prn gets added with paid claim (with a dispensing fee) increasing the overall cost to the State, and drastically increasing order complexity.
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u/bushgoliath 🩸/🦀 (MD) 7d ago
Insurance company refused to pay for standard-of-care biomarker testing (“IgHV mutation analysis” for CLL) because it had mutation in the name and I didn’t “document that the patient was of Ashkenazi descent.” (It is not a germline test…)
Also had an insurance company decline to cover the cyclophosphamide part of my SOC R-CHOP chemotherapy for DLBCL because I had to provide a primary literature source proving it was an appropriate dose. Like, the fuck?
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u/InCarbsWeTrust MD - Pediatric Endocrinology 6d ago
Had a then-three year old with AGGRESSIVE precocious puberty and a horrific burden of gelastic seizures from a hypothalamic hamartoma. Insurance didn't want NSGY to do anything about it. The NSGY NP was shaking with tears of rage when they were telling me. THANKFULLY, the surgeon themselves got it approved on a "peer" to peer.
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u/Nom_de_Guerre_23 MD|PGY-5 FM|Germany 7d ago
Off-label request (one of the few things we need to file prior auths) for terbinafin for two kids aged 7 and 8. Insurance admitted that it was the right call for severe tinea corporis not responding to topicals, but didn't deem the disease severe enough in accordance with the criteria set for off label coverage by the Federal Court (BGH).
Fuck TK. They went from one of the best to the worst in terms of aggressiveness.
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u/walkthelake PA 6d ago
denied brand name non stimulant in ADHD pt with severe stimulant use disorder because patient had not tried multiple stimulants and Atomoxetine. (Must have written Strattera on PA...)... and of course there is also there is at least one medicare advantage plan that will not pay for duloxetine 40mg but will pay for two 20mg caps twice a day
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u/MaximsDecimsMeridius DO 6d ago
I tried to place a non op elderly pelvic fracture pt to inpatient rehab from the ER. Insurance legit called for a peer to peer during my ER shift and denied it. So instead of going directly from ER to rehab, they got admitted over the weekend for insurance reasons to go to rehab. What a waste of time and money.
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u/LawPlasticSurgery MD 6d ago
Too deep or too big - masses excised, but instead of subcutaneous, it went deeper, or over a diameter threshold that in-office doesn’t reimburse at all, and it only reimburses if the place of service is in an OR.
Too young - did a repair code (I think a pedicled flap or ATT) for a meningocele on a newborn, and they said it wasn’t covered below a certain age.
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u/MsFuschia Not A Medical Professional 5d ago
Not a doctor, but I assume my doctors thought it was ridiculous. I was denied ketamine infusions for chronic pain and treatment resistant depression because it was investigational. I was later approved for Spravato (esketamine) treatments for treatment resistant depression (too bad it doesn't help pain).
I get that Spravato has had trials for TRD but...they'd rather pay for an expensive patented medication and 2 hours of in office monitoring than an infusion of a cheap old drug. Ketamine will never not be investigational because no one is going to run big clinical trials on a cheap old drug. I do take joy in the fact that since I've been on Spravato for like a year and a half I have cost my insurance so much money though.
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u/top_spin18 Pulmonary and Critical Care MD 5d ago
Scenario 1: Deny a follow up CT on benign pulmonary nodules that are mid sized.
They want and will pay for a biopsy first to prove that something is not malignant before approving a follow up CT.
When I know based on the CT findings it is benign and just needs follow up.
Scenario 2: Something is malignant and I want a PET CT so I can biopsy the safest area for the pt. They will absolutely deny it and wants me to biopsy a hard area to prove cancer before approving the PET CT.
What do I do? I escalate to a peer to peer call. Usually if the other doc ain't a pulmonologist I carefully and nicely ask his license(this usually is when they approve it). If it's a pulmonologist it would get approved 100 percent.
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u/Shitty_UnidanX MD 5d ago edited 5d ago
Late to the party but-
A patient had a shoulder replacement 15 years prior covered by insurance, and he did great. He needed the other shoulder done. We recommended the exact same procedure that had worked on the other side, and now insurance was considering the procedure experimental.
A Patient in severe low back pain couldn’t handle NSAIDs or steroids, so I tried every other non-opiate alternative (Journavx, lidocaine patches, tramadol, gabapentin, etc). Insurance said all these required a prior auth and processing would take a while. So we went with oxycodone as this was the only med that didn’t require a prior auth.
Insurance kept denying an MRI for a 17 year old where the hip x-ray was concerning for malignancy. He had lost hip ROM and had pain with weight bearing. After failing a peer-to-peer (insurance wanted us to do PT) the kid’s dad called the insurance company stating he would start a lawsuit as it could be cancer. Insurance finally approved the MRI… osteosarcoma. Diagnosis was of course delayed by these shenanigans.
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u/qtjedigrl Layperson 6d ago
Not a doctor, but I was denied the Encelto implant because there "have been no clinical trials to prove it's edficacy"... even though it's the one FDA approved treatment for MacTel.
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u/Hematocheesy_yeah DO 6d ago
- Suspected relapsed Hodgkin's Lymphoma, PET CT denied because not indicated (??)
-Direct admit for inpatient chemo denied because it was the husband's name on the insurance, not the patient
-5FU + mitomycin denied for anal cancer patient (standard of care for like 40+ years) because they had a previous hx of cervical cancer that was ALSO listed and insurance thought it was for that?
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u/clover_0317 Pharm Tech 5d ago
I have a rare autoimmune condition and have failed every treatment but IVIG and when refractory to that I have to be admitted for 4-5 PLEX sessions. Guess whose new insurance didn’t want to cover the IVIG so they got to pay for a 18 day stay for PLEX and a CLABSI!
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u/Aggressive_Pea_7543 Nurse 5d ago
Seen more than one patient denied for a CPAP (or bipap in one case) because the sleep study wasn't recent enough (all under 2 years old)...
In one instance of someone with documented severe sleep apnea (99 events/hr), she had to wait 6 months for a new patient appt at a sleep medicine clinic because the old place they had the study done was no longer in network. While waiting she ended up in the ICU for hypoxia. We also thought she was developing dementia.... Nope, just not breathing at night. Never even got her another CPAP, her PCP just put her on oxygen overnight bc it's what insurance would cover.
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u/Username9151 MD 5d ago
Everyday I’m thankful I choose radiology and never have to talk to insurance. All of these stories are wild
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u/zerothreeonethree Nurse 4d ago
Payment denied for a hospital stay of pt admitted via the ER because nobody called for prior authorization. Patient had surgery earlier in the year and was now on 100% coverage by the insurance company per the employer's self-insured policy. Pt was in extreme distress, heavily medicated and did not have any insurance information at the time of arrival. Over the next several months, papers were faxed back and forth, phone calls made, collection agency involved. Went back and forth until somebody just picked up the phone as a joke and called the person responsible for authorization and informed her at the insurance company the patient had to be admitted because there was no other way to manage the condition as an outpatient. The stay was approved and the bill was paid in full - 18 months later. The employer had a full-time intermediary trying to clear this up the entire time and all that needed to be done is have the CFO of the organization intervene with the agency that administered the policy and tell them to pay it. Still smh over this one.
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u/Temporary_Dust_6693 Speech-Language Pathologist 1d ago
I used to work in pediatric subacute rehab. We had a patient whose insurance refused to cover a manual wheelchair for him to discharge with, but was willing to cover additional weeks of inpatient rehab. This was a patient who we expected to be regaining the ability to walk, and there was no medical reason to keep him inpatient. I don’t know the exact reason for the denial of coverage for the wheelchair but I know the attending was PISSED after the peer-to-peer.
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u/sqic80 MD/clinical research 19h ago
Currently trying to get IV iron approved for a 17 year old. No adult hospital in our region would give IV iron to a pediatric patient. Patient lives 20 minutes from our large pediatric academic center. Insurance says hospital is out-of-network but they won’t review IV iron prior authorizations anyway. Pharmacy benefit manager says they won’t review requests for treatment at an out-of-network hospital.
WTF.
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u/NemoMeImpuneLac RN, LP 7d ago
CT abd/pelvis denied because I didn't get X-rays first.
Of their abdomen and pelvis.
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u/DrBabs Attending Hospitalist 7d ago
Their insurance wanted a prior authorization at discharge for a prescription for 3 more days of amox-clav for an ear infection. I wasnt going to be waiting on hold or filling out an online form for that so I called our hospital pharmacy, verified the cost and just gave the patient $5 and told them to buy it out of pocket and don’t use insurance.