Authorization Denied: When Health Insurance Becomes a Barrier to Treatment

Nestled between the Bronx and Manhattan, the most serene location I’ve ever found in New York City is the Harlem River at 6:00 a.m. Mondays through Saturdays.

The murky water reflected the impending sunrise off its oily sheen. After attaching the riggings to the shell and climbing in, both the stillness and the serenity of the river rippled away.

I rowed for three years in college. The dreaded two-a-days workouts and indoor erg pulls were the only downside to trolling between Yankee Stadium and the Broadway Bridge. At some point during my third year, I began to notice a dull ache in my hip after practice. Nothing some rest (and ice cream) couldn’t fix. As race season ramped up, the pain intensified and was less willing to subside with my self-prescribed therapy à la mode.

I sought treatment with the athletic department’s trainer. “Just ice it and it will go away,” they said. It didn’t. Back to the trainer’s office. “Have you tried heat? It will help.” The pain persisted. I then went to my family practitioner. “Have you tried a course of anti-inflammatories?” Yes, but just like everything else so far, no relief.

In the meantime, race season had ended, finals were approaching and I found I was having trouble walking back from the subway after work. I was given a referral to see an orthopedic surgeon. After performing a few quick tests, my orthopedic surgeon told me we needed an MRI and it was possible I had torn “something” in my hip.

Jumping Through Hoops for Insurance Authorization

The MRI order was promptly denied by my health insurance company. However, they approved an x-ray of my hip. My doctor and I agreed that although the MRI was what he had ordered, I should go ahead and get the x-ray taken.

Results: “Unremarkable.” Back to the doctor so he could inform my insurance company I needed an MRI. Again, it was denied with a note indicating it was “unlikely a 22-year-old female is having difficulty walking.” However, they approved a CT scan with contrast. Not a procedure I’d ever like to repeat, but I got it done (at, of course, the facility my insurance company identified).

Back to my surgeon who said, “We still really need an MRI to see what is going on.” Turns out, the CT scan had been inconclusive. On the plus side, they had injected some lidocaine and I was feeling great! (For a mere two days.)

The MRI was finally approved and done (again at a facility identified and approved of by my insurance company). The results were in. I had “an acetabular labrum tear and possible degenerative changes.” In English, please? I tore a small piece of cartilage near the femoral head and the pelvis, and there were indications of arthritis.

I was then informed the surgery did not come with a guaranteed success story. In fact, it was unclear whether the effects of the surgery would last a few months or the rest of my life. “What about if I want to have kids?” We don’t have the research. “Will I be able to go back to rowing?” Absolutely not. “What about hiking? Walking a strong dog on a leash?” You should be okay. “Dancing? Running? Bicycling?” All of those are fine—but no yoga or Pilates. After this surgery, you will be forever restricted from those activities and anything that isolates the hip muscles and joint. I was 22 and contemplating what my life would look like with a perpetual cloud of uncertain future surgery and/or restrictions.

I went for a second opinion (as you might imagine, not covered by my insurance company) and a review of all the studies performed on my hip. I went to a prestigious hospital in New York City to consult with a doctor that spends the large majority of his time on torn acetabular labrums. It turned out to be an incredible waste of time. I was seen by the doctor’s physician’s assistant, who listened to my description of the pain and its duration. The doctor himself came in for less than four minutes. During that time, he spoke rapid-fire and there was no time for any of my follow-up questions. He told me my MRI images were “far too fuzzy to even interpret,” and, “I’d have to measure your legs if I’m going to do this surgery—it might have to be a total hip replacement, I’m not sure yet,” and, “You’ll have to get new MRIs done at the place I like down on 58^th. Go there and have them sent back over to me and we’ll go from there.” And then he was gone. And so was I.

It was time to schedule surgery with my orthopedic surgeon, which my insurance company again denied. My doctor appealed the denial on my behalf, explaining I was an otherwise perfectly healthy 22-year-old who could not walk without pain.

Denied again. My surgeon called to explain the denial. He indicated that often the denials are decided by employees of the insurance company who have little to no medical training or background, but rather follow a set of parameters provided. He again appealed on my behalf, using the multiple studies as support for the surgery. At this point I was tired of the run-around and constantly having to rely on someone else to advocate on my behalf. A short time later, the surgery was finally approved.

Becoming My Own Advocate

I was elated to find out that not only was the surgery approved, but so were 24 visits to a physical therapist after surgery. The physical therapy was to be performed at a location entirely inconvenient to both my home and office locations. I did some research of physical therapy centers closer to my home and office and sought the advice of friends and officemates. I was fortunate enough to work as an administrative assistant in a law firm specializing in medical malpractice at the time—so the advice was well taken. I took that information and called my insurance company myself.

I explained that the location they had identified to attend physical therapy sessions was inconvenient and was not the location where I wanted to seek treatment. I gave them the name of the facility not two miles down the road from my office, which was accessible during my lunch hour and okay with my employer. I expressed my willingness to attend physical therapy (I really wanted to get better and get back to what I was doing) and that I took my healthcare very seriously. I was told a decision would be made but that there were no guarantees and I shouldn’t get my hopes up.

To their credit, the insurance company approved my physical therapy at the location I designated. I got the approval letter in the mail and it seemed like it was all coming together. The surgery was a few days away, and I had the physical therapy all lined up—now all I needed to do was rest, recover, and get back to my daily life. Until I scrutinized the letter—which indicated they had only approved 18 sessions of therapy at that location. I rooted through all my paperwork (and there was a mountain of it) to find the other approval letter that allocated 24 physical therapy sessions. I looked at them. And read them again. Read each one over—placed them side by side and upside-down. One said 24 sessions. The other 18. Apparently, asking to have the same treatment at a different facility resulted in the loss of 6 sessions.

I gave the papers to family members to read to ensure I wasn’t missing anything. I asked the attorneys in the firm to glance over them. Nobody could explain the loss of 6 sessions of physical therapy on the eve of surgery simply by switching locations, and I still had unanswered questions that no one seemed to be able to answer. But I knew someone who could.

A telephone call to my insurance company confirmed they had unilaterally decreased the number of sessions I needed post-surgery. I placed a call to my doctor’s office to let him know what had happened. He agreed the facility I was now going to attend was superior to the one identified by the insurance company, but there appeared to be no rationale as to why they slashed 6 sessions from my treatment. He told me not to worry—we would start with the 18 treatments, and he would prescribe more if I needed them.

The surgery was a success. I awkwardly clunked around on crutches for two weeks until my post-operative visit with the surgeon. He had the biggest smile and asked (with far too much enthusiasm) if I wanted to see the photos from the surgery. No, I did not. Turns out, it wasn’t a question; we were going to review them together. We looked at the tear—which was much worse than previously seen on the MRI. We looked at the femoral head, which had a lot of arthritic bone that was removed during the surgery. We reviewed every detail of the surgery—and I was finally given clearance to attend physical therapy and take a proper shower.

Hitting the Wall

After 18 sessions of lunch-hour physical therapy, the physical therapist and my doctor agreed I needed at least 18 more sessions to ensure proper healing and that the surgical repair would last. They both prescribed 18 more sessions. However, the insurance company had not made its decision regarding the continued treatment before my next scheduled session.

I asked the physical therapy facility if they would be able to provide treatment in the interim. They were willing to help, provide treatment and lend support wherever they could. A few days later, I received an approval letter for continued physical therapy sessions from the insurance company. Six more sessions. One-third of what had been prescribed by treating professionals.

I grumbled and fought with the insurance company, roping in my doctor and the physical therapist. The insurance company wouldn’t budge and refused additional treatments. 24 sessions in total were the most they would cover, and if I wanted to continue I certainly could—paying out of pocket, of course.

I attended my last 6 sessions, keeping in close communication with my surgeon and the physical therapist. I asked if I could have them draft and approve a home exercise program that I could do at home in lieu of paying out-of-pocket for continued visits. They both agreed this was an excellent idea—but if there was any pain I was to return to their care immediately.

Creating the Spark

While all of this was going on, I had been working in a law firm while trying to figure out whether I really wanted to go to law school. I had been working in the same firm for over seven years at that point, and I wanted to make sure that law school was really and truly my dream. Going through this experience only solidified my desire so that I could advocate for others. Along the way I learned how to effectively advocate for myself both in and out of a legal forum, and I am always enthusiastic about using my skill set to the benefit of others.

It’s been over eight years since the surgery. I can live without yoga and Pilates. My husband and I (attempt to) ride a tandem bicycle on occasion. I’ve hiked a portion of the Appalachian Trail while pregnant. I chase after my son on uneven terrain and skillfully dodge dump-trucks in my living room.

It’s no longer the dark waters of the Harlem, but I’ve found serene places all over the DMV—and I can’t wait to find more.

Useful Tips for Those Dealing With Injuries:

• Be your own advocate.
• Talk to your doctor and ask questions.
• Bring a notepad with questions you have and space to write down what the doctor says.
• Discuss your symptoms with your doctor and ensure you both have a clear understanding of the course of treatment.
• Ask why your health insurance, or your employer’s workers’ compensation insurance (if you were hurt on the job), is denying treatment recommended by your doctors.
• Work with your treating providers to find alternatives while you’re waiting on authorization (or if authorization is denied).
• Be persistent. Sometimes, it will take several “nos” to finally get a “yes.”
• If insurance is requiring you to go to a provider that doesn’t work for you, see if there are alternatives available. Do the research to find a better location that accepts your insurance.
• Don’t be afraid to ask your doctor to advocate on your behalf for necessary treatment.