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I read on-line (and sometimes on this forum) of people having issues getting pouch scopes etc. I was wonder if maybe a new Forum related to health insurance would be helpful.

I've not had a scope for 4 years b/c of cost.

For me, I spent 2 weeks trying to convince my insurance company that a "flexible sigmoidoscopy" is the same as a colonoscopy, but for J-Pouchers. A smaller "tool" is required and it is coded this way so the room is prepped correctly.

They declined to cover it as "preventative" and asked for a $1300 copay, which I cannot afford. This is a slight improvement over the $3000 that BC/BS wanted me to pay.

Took 2 days to get my doctors office (and they are GI specialists!) to code the procedure correctly for someone with a J-Pouch.

Anyway, curious if a forum related to insurance issues and how others may have had success navigating the cryptic diagnostic and procedure codes.

 

Original Post

We already have a lot of forums, so it probably will not happen.

Also, there are so many variables. Different health plans and health plan companies. Different providers. Different states. The ACA regulations are nationwide, and the “no cost” colonoscopy is part of the ACA. However, to be “no cost” it has to be a routine screening colonoscopy. Once you have symptoms and/or a diagnosis, it is for diagnosis or follow up/maintenance. If you have a j-pouch, you ovbiously have a prior related diagnosis. Of course, this may all change if the ACA is repealed.

I think you were just lucky to convince your providers to code your scope to be covered under the ACA. Both my husband and son have UC (and their colons) and so not qualify for “no cost” colonoscopies and their procedures are subject to their deductibles. My brother had a bleeding hemorrhoid (symptoms) so his colonoscopy was diagnostic, not routine screening.

I was able to successfully petition my health plan (through the grievance procedure) to charge my scope as a flex sig without sedation, when it was incorrectly coded as a colonoscopy, by mistake. 

The point is that there are a number of things to take into account. I do agree that healthcare is still too expensive, and the premium assistance is not offered to enough people. The middle class is screwed. It will get worse with the removal of the individual mandate and more healthy individuals drop their coverage.

Jan

Last edited by Jan Dollar

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