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  • alcohol ablation & insurance coverage

    [alcohol ablation & insurance coverage]

    Author: Judy Perkins (---.proxy.aol.com)

    Date: 07-21-02 14:04

    I'm not sure how long I have had HCM but within the last year I have gone from working a full time job and two part-time jobs to just being able to work the full time job and that is getting harder and harder to accomplish. I am a medical transcriptionist so it is not as if I do really vigorous work but I can only seem to work about 2-3 hours at a time and then have to nap. I have 80-90 gradient and have been scheduled for acohol ablation by Dr. Bach at Barnes Hospital in St. Louis. The day before I was to go to St. Louis for the procedure, the insurance company informs us that they will not cover it as it is considered "investigational". We are appealing the decision. Does anyone have any experience with insurance companies in this setting and what we can do to get this covered. I am new to the forum but have read just about everything on here. I have learned so much from this site and really appreciate it. I have more and more questions about this disease every day and hopefully you all will be able to help me. Thanks for everything.

    JUDY

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    [Re: alcohol ablation & insurance coverage]

    Author: Jerry Salzman (---.indy.rr.com)

    Date: 07-21-02 16:50

    Judy,

    I haven't gotten quite far enough to ask my insurance about this yet, however in my hunts through the net I have found where some insurance companies have now considered ablation as standard. I would try to search on insurance and ablation and see what you get, although I bet Lisa already could answer this. Also, the other option is a myectomy and I am sure it costs more than an ablation. It would be interesting to see if insurance would opt for the more expensive procedure.

    Jerry

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    [Re: alcohol ablation & insurance coverage]

    Author: Lisa Salberg (---.dyn.optonline.net)

    Date: 07-21-02 18:15

    HI guys -

    Re insurance coverage for ablation - many companies are covering the procedure, while it has not been deemed "standard of care" by the cardiology population at this time it is more common than a few years ago. I am only aware of 1 company who refused out right - this case is still under appeal -

    RE the cost of myectomy vs. cost of ablation I would ask for caution here - - While yes the billable amount for surgery is higher than ablation - - the procedure also comes with far more expenses - - ex. cath lab vs. a surgical suite , 3-5 days in for surgery vs. 1-2 for ablation. While yes myectomy costs more, ablations need to be redone far more often (this taking away from much of the cost benefits.

    While cost is always important, this is not the time for price hunting, there are many reasons why one procedure may be better for some people over the others.

    I continue my words of caution to all those seeking ablation or myectomy... Make sure you are going to a center with a good deal of experience. Many doctors feel they can perform the procedure just because they were shown how... HCM is NOT a disease of obstruction it is a disease of cell structure and the WHOLE disease/heart must be treated.

    JUDY - these words are not meant only for you they are a general posting for all those in a similar situation.

    Barnes is an excellent hospital overall as I am sure you know Judy, but it is a good idea to ask how many have been done there and ask if it is not possible to do the ablation (due to the inability to locate the proper location in the septum - which can happen) what happens, are they ready to perform surgery or must you go elsewhere?

    The insurance company should fight it out with the dr, you do have a right to appeal if they say they will not pay - - the patients bill of rights gives you this protection...let your ins. company know you are ready willing and able to fight it out with them.

    Best wishes,

    Lisa Salberg

    HCMA

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: alcohol ablation & insurance coverage]

    Author: Judy Perkins (---.proxy.aol.com)

    Date: 07-21-02 18:25

    The insurance company already said they would pay for the myectomy but I am more inclined at this point to go with the alcohol ablation. In the appeal I am hoping the 'money' aspect of the two will be the deciding factor with the insurance company (it probably would be if my insurance company is any indication of all of them ha ). With alc ablation I don't think I will be off work as long as the myectomy either. Thanks for your input. I really appreciate it.

    Judy

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    [Re: alcohol ablation & insurance coverage]

    Author: Judy Perkins (---.proxy.aol.com)

    Date: 07-21-02 18:36

    My insurance is United HealthCare. I am employed by a local hospital here in Columbia, MO that is owned by the University of MO and the insurance is through the University. My physician at Barnes is Dr. Richard Bach and it is my understanding he has done about 12 of the ablations with Washington University in St. Louis. I do have a question though, after an ablation and/or myectomy is performed are most people able to go back to their normal lives, etc. I have gathered from this forum that HCM is something that I will have always rather or not either procedure is performed. It was my understanding that I would be pretty much symptom free after one or the other of these procedures. I really appreciate your help in this matter and helping me understand HCM overall.

    JUDY

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    [Re: alcohol ablation & insurance coverage]

    Author: Sarah B-Board Moderator (---.ipt.aol.com)

    Date: 07-22-02 01:11

    Dear Judy

    Everyone is different and I've read posts from people who felt "cured" after an ablation and, sadly, of one person who didn't make it through the procedure --just to give you an idea of the range of experiences.However, most people will have a great reduction in symptoms, but you may still need medication.

    This is why it is so truly vital to have the procedure performed by someone who does them all the time.

    take care

    Sarah

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: alcohol ablation & insurance coverage]

    Author: Lisa Salberg (---.dyn.optonline.net)

    Date: 07-22-02 10:29

    HCM is a genetic condition that has marked effects on the "pumping" and "electrical" portions of the heart. Ablation and Myectomy can improving some actions of the "pump", by allowing greater blood flow and limiting mitral valve insufficiencies it CAN NOT change other aspects of the "pump" such as the ability of the heart to relax, while some do have improvements in this area of the heart it is not something that a simple reduction of the amount of tissue can change. The cell structure is "wrong" and causes the heart to not be able to relax, there by creating some of the symptoms connected to HCM.

    Having a procedure (either noted above) is not going to stop the cell structure from being what it is. Also it is not going to make those cells any more able to relax.

    It will not change in any positive way your hearts electrical system. In those with Ablation, a significant % will encounter more electrical problems; this has not been seen in myectomy.

    Neither procedure will do anything to reduce your risk of Sudden death or change your life span; either procedure may help you reduce some symptom associated with HCM.

    If you are seeing a doctor (whoever and wherever) that makes you believe you will no longer have HCM or be "cured" they simply do not understand the diseases and you would be well advised seeking a 2nd or 3rd opinion.

    I know this is a complicated and stressful process but I cannot state strongly enough how important it is to make clear, well understood choices. This is your heart with either procedure there is no turning back and if you make a mistake...that’s it your stuck with the outcome. Yes you may be able to have a 2nd procedure...but who wants that, (no Ins co I can tell you that!)

    This message board is not replacement for you from a doctor’s evaluation of your situation, so TALK to your doc's and if needed get others involved in your care.

    By the way I have spoken to a few "dr" friends about the man your speaking of and he has a good rep and is known to have preformed the procedure at least 9 times that they were aware of.

    Best of luck and if you need us please call the office!

    Lisa Salberg

    President,

    HCMA

    973-983-7429

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: alcohol ablation & insurance coverage]

    Author: Judy Perkins (---.proxy.aol.com)

    Date: 07-22-02 13:17

    It was not Dr. Bach who led me to believe I would be back to normal but my local cardiologist that referred me to Dr. Bach. I will indeed talk further with Dr. Bach and beginning to wonder if I shouldn't have the myectomy instead. My shortness of breath is so intense I can hardly walk 50 feet without extreme shortness of breath followed by chest discomfort. Thank you so much for your input. I really appreciate everyone's input. I will definitely do more research before either procedure is done.

    JUDY

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    [Re: alcohol ablation & insurance coverage]

    Author: Craig C (---.ph.ph.cox.net)

    Date: 07-22-02 13:23

    Dear Judy: I was diagnosed with HOCM in March of this year and had the alcohol

    ablation done in April. Insurance covered the costs without hesitation. My ins. is a PPO, so I don't know if this had anything to do with their decision or not.

    But I'm writing to let you know of my physical experience. the actual procedure was quite painful, although I'm told that is unusual. Versed and morphine used in the procedure is supposed to allay this pain.

    12 hours after the procedure I had an "episode" which was painful, but after that, all pain was gone and the rest of my hosp. stay was easy. I was in the hosp. for 5 days. This is probably 2 days longer than is normal, but I was 120 miles from home so I'm sure this played a part in the length of stay.

    I was off work for 3 weeks, but could have gone back after 2 wks. My job is very physical so I'm sure the Drs. were overly cautious.

    Although I feel "cured" now, we all know this is a genetic defect that cannot be cured at this time. This procedure, I feel, is a Godsend. Compared to cracking the chest this is a piece of cake.

    Judy, all my Best Wishes and Prayers to you. Hopefully all will be resolved in the way you need.

    Sincerely,

    Craig Cowen

    ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

    [Re: alcohol ablation & insurance coverage]

    Author: Judy Perkins (---.proxy.aol.com)

    Date: 07-22-02 18:54

    Craig, thank you so much for your message. I feel so much better about the whole thing after reading it. I too live about 120-125 miles from where the procedure will be done. I have a POS insurance (not HMO), so I don't know what their problem is. I am appealing it and hopefully things will take a positive turn. Again, thank you for your encouragement and hope everything continues to go well with you.

    JUDY
    NOTE: This is a post from the previous forum message board.

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