r/HealthInsurance • u/Kamikazepyro9 • Apr 09 '25

Medicare/Medicaid Insurance denied my wife's medically necessary hysterectomy. How do I appeal? Tips for this fight? (Colorado Medicaid by United Healthcare if it makes a difference)

As title states, we have had my wife's hysterectomy scheduled since December. We were notified today that insurance denied the authorization. Her OBGYN and our Primary Doc have both said it's medically necessary.

What steps do we need to take to fight this decision? They want her to "try other methods" but we've already gone down that route and jumped those hoops. This has been a multi-year fight to get to this point for it to be denied...

Edit: Got the denial letter in today - reason for denial is due to them only looking at our history with our current OBGYN (1ish year)

They did not look at her history or any medical records from other OB offices and our primary doctor office.

Even though they have access to this data, I'm compiling it all into a single documented point to send alongside the appeal letter. Her OBGYN has also said she'd be requesting a peer to peer review as well.

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19

u/Littlelilps7069 Apr 09 '25

Call the gyne, ask them to appeal on your behalf. It's possible that the actual hysterectomy is approved as outpatient/1 night in observation ,and denied for full inpatient admission . If that is the case, The gyne will have to resubmit request. You can also call your insurer and ask to speak to a case manager.

-2

u/cheeseybacon11 Apr 09 '25

People do hospital stays for those?

8

u/lysistrata3000 Apr 09 '25

Complications do happen. Mine was a 23 hour obs stay though.

7

u/This_Acanthisitta832 Apr 09 '25

It depends on your individual health, how you do after surgery, and which approach is used for the hysterectomy (laparotomy, laparoscopy, vaginal, or robotic).

3

u/Liberteez Apr 09 '25

My Mom was in the hospital for two weeks.

3

u/cheeseybacon11 Apr 09 '25

Wow, the one person I know who had that done was in and out in like 5 hours, so I didn't know it could be so intense.

1

u/ReasonKlutzy5364 Apr 09 '25

3 days for mine but this is when they did them as Inpatient.

2

u/Bulky_Rope_7259 Apr 09 '25

Yes mine too. Hysterectomy can’t always be done via laparoscope/vaginally. Mine was abdominal 3 nights in hospital.

1

u/NectarineSmooth9408 Apr 09 '25

They do. I had one 3 weeks ago and due to not waking up fully from the anesthesia and throwing up, they kept me for a day to make sure I was ok. I’m not sure about Medicaid though UHC but I do have insurance through my employer and Medicaid(Colorado)I also tried 3 months of birth control before we got a surgery scheduled so not sure if that helped the decision.

1

u/CancelAshamed1310 Apr 11 '25

Most go home these days

1

u/SphynxCrocheter Apr 13 '25

Yes, I was two nights in the hospital for a pre-menopausal hysterectomy that was medically necessary.

0

u/kit0000033 Apr 13 '25

I was in the hospital for three days after mine... But they opened me up hip to hip... Most people have them done laparoscopically and have less of a hospital stay... It's still major surgery though.