Saturday, February 4, 2012

Roller Coaster

This last week has been a real roller coaster ride for me, often feeling like I was dropping over from the top with no seatbelt or shoulder harness, nothing to hold on to.

My last post detailed everything that's been going crazy in my life - the most traumatic, of course, being the idiotic health insurance company that decided to reject my doctor's request for authori
zation for the final surgery of this two year adventure of breast cancer.

The Medical Director on the company rejected the request a second time, again because it was for 'cosmetic' purposes. Jerk! So Kim, my doctor's VERY able assistant, after many choice words, arranged for the Medical Director to call my doctor to discuss my case. Incredibly, he was so busy that he neglected to make the call and did not return three calls.

I was so dejected, devastated, distressed and demoralized - had no idea it would affect me so much. I just want this whole thing to be over with! It's been a LONG two years. This surgery would be number nine - nine in two years. Nine doses of funny anesthetic juices plus all that chemo poison - it's no wonder what remains of my feeble brain is hiding in a corner of my head and refusing to come out to visit!

Anyway, we finally had to cancel the scheduled surgery, but Kim insisted I not give up - that she would continue to fight for me.

Meanwhile, I had received my copy of the rejection letter from the insurance company. They weren't even polite en
ough to tell me 'why' my request for 'Mastopexy' was denied, just that it was. But they did tell me how I could appeal the decision.

The appeal letters that I've written (in my head) are, so far, not really very gracious. I have to let out a huge amount of vitriol before I can write an acceptable letter.

I mean, really - the Medicare protocol is very plain and simple. It reads (color highlights are mine):

Medicare National Coverage Determinations Manual

Chapter 1, Part 2 (Sections 90 – 160.26)

Coverage Determinations

Table of Contents

(Rev. 140, 01-06-12)

140.2 - Breast Reconstruction Following Mastectomy

(Rev. 1, 10-03-03)

CIM 35-47

"During recent years, there has been a considerable change in the treatment of diseases of the breast such as fibrocystic disease and cancer. While extirpation of the disease remains of primary importance, the quality of life following initial treatment is increasingly recognized as of great concern. The increased use of breast reconstruction procedures is due to several factors:

A change in epidemiology of breast cancer, including an apparent increase in incidence;

Improved surgical skills and techniques;

The continuing development of better prostheses; and increasing awareness by physicians of the importance of postsurgical psychological adjustment.

"Reconstruction of the affected and the contralateral unaffected breast following a medically necessary mastectomy is considered a relatively safe and effective noncosmetic procedure."

OK - I had to look up a couple words there. "Extirpation" means pretty much what you'd expect from the sentence - 1. To pull up by the roots. 2. To destroy totally; exterminate. 3. To remove by surgery. And the 'contralateral unaffected breast' is obviously the little (big!) boobie that hasn't been carved on yet.

So what's to question there - Medicare says in plain English that it is a noncosmetic procedure. So if that isn't plain enough, how do I appeal the decision??

My thoughts ran along the lines of:

OK, if you jerks don't choose to follow the Medicare protocol, how about this. I have had a partial hip replacement on my left leg after suffering a break in a fall in 2007; I have a mangled left knee from an auto accident in 1974 which causes me pain with every step I take; I have a crushed right ankle from the accident in 1974 which causes chronic severe pain from degenerative traumatic osteoarthritis; I have had my right knee replacement due to the damage caused by my very awkward way of walking from the various injuries; and I have moderate degenerative osteoporosis in my right hip. Now I have a contralateral unaffected breast that weighs about five times as much as the reconstructed breast. This following the radical mastectomy that left me with a hideous deformity instead of a simple scar, leaving me no option but reconstruction. This significant weight imbalance creates a major strain on my spine, causing me intensifying back pain, not to mention the increased propensity to fall, meaning the possibility of more broken bones. Perhaps you'd like to pay for a hip replacement or back surgery instead of a mastopexy?

Needless to say, my humor has been less than joyful. My girlfriend arrived Thursday for a few days even though I no longer needed a caretaker, and we've had several bottles of champagne, and that always helps!

Thursday there was no word from Kim about the idiot Medical Director coming through with a phone call, and my hopes were sinking. Yesterday, she called and asked what I wanted to do on Tuesday. I said I wanted to go to the hospital, and she said OK! My sweet doctor finally made contact with the insurance clown and convinced him to change his mind! I get to have the surgery!!!

It's kind of weird that I'm rejoicing because I get to have my poor abused body sliced up again, but I am. I'm so relieved
to have a decision made and to see a light at the end of the tunnel!!!

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