UAE and My HMO
For participants of the eGroups embolization list
Hello, Embo-listers and whoever else finds their way here.
Ive very hurriedly typed up most of my correspondence in regard to my HMO appeal process for Uterine Artery Embolization.
Here are the documents, with most personal names and ID numbers removed. Im of course publishing my own name and also the names of the chief medical directors of Foundation Health Systems, the HMO conglomerate that bought my health plan, Intergroup of Arizona, a few years ago.
1) Intergroups first denial. My gyne had referred me, at my request, to an interventional radiologist for uterine artery embolization for treatment of uterine fibroids.
2) My first appeal. Intergroup calls this an Informal Reconsideration. It was accompanied by a booklet of articles on UAE, supplied by the IR Id been referred to. (Note: Within this appeal, I've included a list of doctors and hospitals where UAE was being performed. I'm sure there are more now, plus the list may be out of date in other ways. It didn't, for instance, include the doctors on the embo list since I wasn't aware of the list at that time. Embo members, please check the Vault for current links to facilities and doctors who provide UAE.)
3) Intergroups denial of my first appeal.
4) Intergroups denial of my second, or Formal Appeal. I dont have a copy of the appeal letter yet. It was written by a patient advocate and accompanied by a great deal of documentation - something like 70-100 pages of articles on UAE. My patient advocate and an Interventional Radiologist from the practice I was referred to both phone-conferenced to the oral hearing, which was attended by several (5?) medical directors and other Intergroup staff.
5) My third appeal. I requested that Intergroup submit my Formal Appeal materials to the Arizona Department of Insurance, in accordance with state law.
6) Foundation Health Systems policy statement on UAE. I hadnt known it existed, much before the Formal Hearing, and so was unprepared to contest the points until the third appeal.
7) My letter to the ADOI in regard to the third appeal.
8) Attachment 1 to the ADOI letter. I argue the points in the Policy Statement as best I can, given only a day to write this. The kind gentleman at the ADOI suggested I address FHSs specific points as to why UAE should be considered experimental. Fortunately, I had the Policy Statement by now and knew what I should be arguing. (Note: I cribbed a couple of sentences each from info posted by Dr. Worthington-Kirsch and Dr. Niedzwiecki on the embo site; you are likewise invited to crib from me, if you wish.... :o)
9) Attachment 2 to the ADOI letter. I argue points notincluded in the Policy Statement, but which I believe to be important.
10) Letter from the ADOI reversing Intergroup's denial.
11) Letter from Intergroup acknowledging the ADOI's overturning of their denial.