Wiki Endometrial Ablation

[wfriddle]

We have been getting a lot of denials stating this procedure is experimental. Some insurances have criteria that must be met before they will consider these charges. For example Aetna wants to see hormone therapy, EMB or D&C and a negative pap smear. My provider is stating that a D&C is no longer the standard of care for abnormal uterine bleeding but I am unable to find the documentation to support this. I have looked on ACOG and could not find the documentation I need. I am trying to appeal an ablation where the provider did not perform either the biopsy or the D&C. Any suggestions?

 

[Bready]

Having the same problem in my physicians' practice. Aetna will not allow a pre-determination nor a pre-certification of the procedure. Says it does not require precert or pre-d BUT after the procedure is done, they hold the claim for documentation that all their requirements were fulfilled before payment. UHC also requires documentation and precert. Have not run into any problems with BCBS or Cigna--yet. The decision by my doctors was to go ahead and jump through Aetna's hoops if the patient wants the ablation. The alternative is a hysterectomy(major surgery for the patient and more expense for the insurance co) which requires no documentation and insurance will cover.

Unfortunately, if you don't have their requirements for the ablation, you're out of luck. Very difficult, if not impossible, to appeal. Your physician can (a) quit doing the procedure which apparently is what the insurance companies want or (b) follow their requirements and submit the documentation with the claim.

Good luck. Would be interested in knowing if you are able to successfully appeal your claim.

 

[wfriddle]

This is the problem I am having, the doctors are aware of the problems we have been having getting these paid but do not agree with the criteria so they are not following it. It is very difficult, like you said, to get paid without the documentation. Unfortunatley it looks like BCBS is heading this direction as well. I am trying to gather as much info as I can to reinforce this to my providers. Thanks for your advice.