Tufts Health Plan
Attn: Member Appeals
To whom it may concern:
I am writing about the letter I received today from Cigna Health Management for myself, participant ID [elided] and reference code [elided].
To be frank, this letter is the worst, most impenetrable, absurd blob of insurance-company doublespeak I have encountered in many years. I am therefore writing to appeal your denial and to ask you to confirm in writing in plain English that you’re not going to retroactively decide to reject the claims for my surgery.
Here is what the letter says:
Inpatient Admission 43281
After review of the information submitted by your provider and the terms of your benefit plan, we have determined the requested service(s) are not covered. This decision was based on the following;
After a complete review of this request and available information, the following decision and reasons for making the decision are provided by Dr. Alan Sokolow:
43281 – Laparoscopy, surgical, repair of paraesophageal hernia does not require precertification under your medical benefit plan because it is performed on an ambulatory basis. Ambulatory services may include an overnight stay in the hospital if needed. Medical necessity for coverage of an inpatient hospital stay for your procedure has not been established and is denied. No information has been received that shows you have a condition that makes it necessary for this procedure to be performed as an impatient.
GUIDELINE: Decision based on the prevailing standard of care
To be blunt, this is nonsense.
The definition of “inpatient” according to the Merriam-Webster dictionary is, “a hospital patient who receives lodging and food as well as treatment.” Another definition offered by the same dictionary is, “a patient who stays for one or more nights in a hospital for treatment.” The plain, accepted meaning of the term “inpatient” is a patient who is admitted overnight to the hospital. Words have meanings; they don’t just mean whatever you say they mean.
The surgeon performing my surgery – who has done it on a regular basis for over a decade – categorically rejects your claim that the “prevailing standard of care” for it does not include an overnight hospital stay (as an aside, note that the doctor who made this determination is not a surgeon and has never performed this procedure). A patient who has undergone this surgery cannot be sent home until they are (a) recovered from their anesthesia, (b) able to move around on their own, (c) able to eat, and (d) tolerating their pain with oral medication. Even though I may achieve (a), (b), and (c) quickly, it could take more than 12 hours to determine (d), because that’s how long it can take for the local anesthetic used to numb the incision sites during the surgery to wear off. Even if my surgery is the first one of the day, by the time the local anesthetic has worn off it may be too late in the day for me to be discharged. For this reason, most patients who undergo this procedure end up staying overnight in the hospital, which means that it is an inpatient procedure despite this Orwellian attempt to claim otherwise.
Leaving aside the absurd attempt to redefine words to mean things they do not, I am more concerned with the question of whether you’re actually going to accept the insurance claims filed by the surgeon and hospital for the surgery. I note that although the letter you sent me claims that this is an ambulatory service; that ambulatory services do not require precertification; and that ambulatory services may include an overnight stay in the hospital if needed, the letter does not define what “if needed” means, seemingly leaving that to the discretion of whoever reviews the insurance claims. Furthermore, although it might seem logical to conclude that the claims will be accepted from the two statements, “This is an ambulatory service,” and “Ambulatory services do not require precertification and may include an overnight stay in the hospital if needed,” your letter does not explicitly state that conclusion, and I’m not so foolish as to think that anything about how insurance companies operate is logical.
Therefore, I need you to answer, in plain English, the following questions:
- Who determines whether an overnight stay after my surgery is “needed” and how is that determination made?
- Will the claims for my surgery and for an overnight stay in the hospital “if needed” be accepted by the insurance company?
- If I encounter serious complications after the surgery requiring staying in the hospital for more than one night, will my doctor need to obtain precertification from Tufts to ensure that you do not reject claims for the additional nights in the hospital?
I look forward to your prompt response to this letter.
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