Your Takeaway: Depending on how a procedure is coded, no pre-authorization for a procedure maybe required. This creates and issue where a denial of treatment may not trigger available appeals on the behalf of the patient. DEMAND A PRE-TREATMENT AUTHORIZATION AND A PRE-TREATMENT DETERMINATION to assure you know the insurance provider’s commitment before your treatment.
After waiting 4 months for a much anticipated Percutaneous Transluminal Angioplasty and Stent of a severely stenosed right jugular vein, I was blindsided by and unexpected issue I was completely unprepared for. 36 hours before the procedure, scheduled 3 weeks earlier, for which I had already been provided preop instructions, I get a phone call from the Financial Department telling me “Because of the ICD code, Medicare considers your procedure experimental, and you will be considered ‘Private Pay’. The procedure is $55,000. Will that be debit or credit?”
They didn’t say debit or credit, I just added that because I was sort of surprised they didn’t say it.
After recovering from a paralyzing fit of hysterical tears and laughter, I asked for the procedure to be postponed. I mean, seriously, who thinks that a patient reduced to Medicare will be able to cough up $55k, or wants to? Up to that point, I had never had a procedure scheduled that hadn’t already been cleared with what “insurance” coverage I had. Whiskey Tango Foxtrot.
A month of phone calls have transpired, chiefly with my Medicare Part B “Provider”.
Seems I’m a caught in a convenient limbo of CPT/ICD codes and the refusal of the Pare B Provider to provide me the transcript of the phone call(s) between my Part B Provider and the hospital regarding coverage of my procedure. Seems I need something called a “subpeona”.
Here’s what you need to be aware of: the CPT code for Percutanteous Transluminal Angioplasty and Stenting does not require preauthorization. However, because Intracranial Hypertension does not yet have a neat ICD code, the only applicable ICD10 code is 167.9, Cerebrovascular Disorders, Other. Having spent a career in health care, I understand how this would trigger a rejection and usually…
…wait for it…
…an appeal to the Part B Provider in the form of either a Peer-to-Peer consult between the doctor and the Part B Provider, or and Advanced Treatement Authorization. At least this is my understanding based on the pieces of information meted out to me over the course of over a dozen phone calls.
Neither of which took place.
Lacking the contents of the phone call regarding my coverage, the only conclusion I can arrive at is that the hospital summarily decided to make me private pay. Medicare doesn’t even cover expenses, so either I pony up or cancel; either way, they don’t loose money. Honestly can’t blame them in this broken bastardized “health care” system where a patient is merely a commodity to be shuffled around so that doctors, hospitals, and insurance providers can exchange money.
My Part B Provider has bluntly told me the contents of their conversation is only available to themselves and the hospital unless I have a subpeona.
That’s helpful. They can rest well; it’as taken too long at his point. And in all honesty, why one earth would I want to set foot in a facility willing to betray the promises of “accomodations” for patients in my unique situation, waiting for my doctor to set up a new program in a new hospital.
The key word: waiting. Another few days. Weeks. Months.
There’s more, but it doesn’t serve the purpose of this Whisper: IIH is a new disorder in a broken medical system more concerned with codes that patients. Make sure you dodn’t get caught in this limbo. Ask for a Pre-Treatment Authorization AND Determination; don’t be blindsided by the broken belief that health care acts in the best interest of the patient; it has become more likely that they will act in their own self-interest. Money over compassion and care.
Prayers to all of us,
The Shunt Whisperer
Missing my Leloo