Health Care Reform Support Group

I have been denied medical care by my health insurance Optima Family Care/Medicaid. I was scheduled for a mastectomy Monday the 14th of September. I received a letter of denial on Thursday the 10th of September informing me payment was denied. Reason listed is no documentation of trial and failure of conservative therapy. I have had 3 surgeries and multiple rounds of antibiotics for the same breast over the last year. I immediately contacted my surgeon. I have contacted Optima and was informed I would be sent an appeal packet and that a member’s service case manager will contact me. I have yet to get an appeal packet, and I insisted on speaking to somebody that could help me. I was assigned a case manager. She has been trying to divert my attention from the surgery denial to my other health issues. I am a diabetic as well as other health issues. I have sent e-mails to every media source I could find online as well as elected officials. I sent e-mails to the White House, I received a call from Linda Brown at regional headquarters in Philadelphia, stating; my mail had reached the president and had been forwarded to her. That per President Obama’s request they are to investigate my case immediately. I went for a consult with my surgeon to discuss my case. My surgeon had a peer to peer interview with the Optima Medical Director. The Medical Director wants me to have a procedure called breast conserving surgery. This procedure is usually done in skin and nipple-areola sparing surgeries. Not recommended in my case, since my entire medical problem is the nipple-areola and the surrounding tissue and skin. The outcome of such a procedure in my case is very poor. The medical director also stated; if I win my appeal for a mastectomy, they will deny payment for reconstruction and if I choose the breast conserving procedure they will also deny reconstruction. Janet’s Law gives me considerable protection for reconstruction, and the state of Virginia gives extra protection and mandates any insurer that provides coverage for a mastectomy must cover reconstruction. In the past year I have contacted both my PCP and Optima and requested to see a breast specialist and was told by both there was no such thing as a breast specialist. However there are breast-specialist. My PCP actually has my request in my medical chart. I feel this story needs to be heard not just for me but also for every American that has been denied necessary medical care by their insurance company.
Posted on 09/26/09, 08:09 am