"We don't have enough evidence that you have cancer"

[u/Lower-Elk8395]

That was the reason as to why United Healthcare denied the pre-authorization for my PET scan. I expected them to fight it, insurance companies HATE PET scans. However, I expected them to pull the "not medically necessary" card...not whatever this is.

They are claiming the 3 pages of documentation and lab results my doctors sent over don't have any factual evidence. Thing is, I have been fighting this cancer for over a year. Every month I get a stack of letters from UHC explaining the services they approved (chemotherapy, hospital admissions, labwork, CT scans, tumor marker tests, doctors' appointments, white blood cell injections, etc.). I was enrolled in their cancer support program (at their insistence, I might add) and get a call every week from a case worker there. What do you mean you don't have evidence I have cancer? Why did you approve my chemotherapy last week then?

No advice needed here, messages to my medical team are already sitting in MyChart, my medical team is absolutely amazing, and I have full confidence that come the 26th they are going to be on a warpath if they haven't already been informed. It just infuriated me to no end to find out that, of all the excuses they could have given, they actually tried to play this card.

UPDATE

First of all, I absolutely love how much this has blown up. I love everybody's responses, I love their stories, and even though my doctors are doing great on handling this I also love the advice being given; I intend to keep it all for the future and I hope it helps others as well! Stories like this need to circulate these days...being quiet about it won't solve anything anymore. I have some updates and I figured I would share!

So for context, I am a patient of the biggest hospital in my state. The head of my medical team who filed the pre-authorization practices there. However, as the hospital is over 2 hours away, they have the day-day activities (blood tests, post chemo check-ups, formerly chemo) done through an affiliate of theirs; a very wonderful oncology center. The chemotherapy specialist who practices there is also a shark who gets quite the thrill out of ruining the days of insurance companies who try to screw over cancer patients.

So, I saw my chemotherapy specialist yesterday...and she has decided she will be throwing her hat into the ring as well. The staff there is pretty skilled at bullying insurance companies and they have managed to secure a CT scan for me come Tuesday. I still don't know how they managed to get this for me so quickly this time of year, but I am beyond thankful as I have a trip the day after my scan. I actually had a bit of a conversation with the nurses while one was on the phone with United, and they shared with me their exasperation at dealing with them and assured me that they know how to handle these guys...based on how well this all went, I believe them wholeheartedly.

The plan is to not only prove to United that I in fact still have cancer, but point out the inconclusivity of the CT scan to get me that PET scan to pre-emptively stop any arguments regarding medical necessity.

So yes, I now have multiple practices out for blood. If United Healthcare wants to play this game then they can pay for 2 scans instead of one. Play shitty games, win shitty prizes. I love all of my doctors and all of my nurses.

[u/LisaMikky]

🗨Their systems are intentionally not functional. [...] The people working there WANT to help and aren't given the tools or functionality to do so.🗨

Considering this, I can't imagine how any normal empathetic person is able to work in Healthcare Insurance and not resign in a couple of weeks, after seeing how things really are. That is, if they somehow had no idea before, which I find hard to believe.

Like - what even makes someone want to work there, knowing part of their responsibilities would be denying help to sick desperate people??? Seems like a job only cruel, heartless and sadistic people could enjoy. (Excuse my honesty.)

[u/xbumpinthatx → u/LisaMikky]

Well, i can answer that. Because if you harassed your manager ENOUGH you might manage to make a good thing happen for someone sometimes. But there's TOO MANY people for a single rep to push for. And I'm talking being the squeaky wheel and harassing your manager and anyone higher up you can for weeks. People need jobs too. I can't speak for other departments but I was hired to work in their business department. I can assure you that none of us truly understand how bad it actually is until you actually see it from the inside and see how uhc intends for you to use the system. So, you accept a job you've now been trained on for months. It gets progressively fucked up as you go along and you're slowly exposed to the actual messed up parts.

Things are explained in ways that might seem like they're not that bad. UHC trains it's employees that things are mostly providers fault, denials are providers faults...etc. You go in and you listen to terrible story after another from customers and you cry too. You do your best to help them and eventually I think it sinks in there's nothing you can actually do to help them. And then you realize that it's actually intentional and nobody intends to fix anything. But it's hard to fully understand until you're on the floor, trained, trying to help these people. It's not like you walk into training and UHC tells you how evil they are. You gradually learn it over time. They have a high turnover rate, I would argue that the majority of people don't stay there from what I could tell. People constantly quitting and being replaced. In fact it happens so much that I was hired to work in their business dept, trained for it, and then on my last day of training told we could work customer service instead or quit lol.

[u/[deleted] → u/xbumpinthatx]

There it is: “People need jobs too.”

[u/LetGo_n_LetDarwin → u/LisaMikky]

This is why Briana Boston was arrested-she said what she said to a lowly customer rep and rather than empathizing, they reported her because you have to be a piece of shit to tolerate working for health insurance companies.

[u/OneEyedWinn → u/LisaMikky]

I am a nurse. Currently full time parent. Family members and friends have previously suggested that I work for a health insurance company as a lower-stress, WFH option for me. I emphatically told them I wouldn’t be able to live with myself if I was the reason that even one person was denied something they needed. I always joked that I would be fired immediately if any actual decision-making was left to me because I’d approve literally anything and everything. I doubt, however, that health insurance nurses have that much power. In fact, in my mind, health insurance companies only hire nurses to be a buffer in between the angry public and their ridiculous policies. I was once in a healthcare roundtable with my former congressman and the (maybe regional?) CEO/COO of BCBS. The CEO bragged that their profits were up 30% that year and another lady at the table asked when her refund check would be issued for the insane cost of her premiums. The CEO did not laugh. We all stared daggers into him.