St. Louis reporter Carolyn Tuft Wilson suffers from a severe airway obstruction which is caused by her jawbones. Her specific jaw structure restricts her intake of oxygen by partially blocking her airflow. She has undergone nine different surgeries in an attempt to correct the condition but her symptoms continue to worsen. As a result, Carolyn suffers from dangerously low levels of oxygen and at the same time, dangerously high levels of carbon dioxide in her body while she sleeps. The condition is so dire that Carolyn's physician fears that she could actually die in her sleep.
Carolyn finds herself extremely worried for her life but also is in a lot of frequent pain. She has episodes where it is extremely painful to breathe and swallow.
Wilson's physician and surgeon both believe her only hope at getting better is an advanced jaw surgery. By design, the procedure would open her airway and increase airflow. But when she submitted the proposed procedure to her insurance company, HealthLink, for preapproval, she was left feeling defeated. As so many health insurance companies do, HealthLink denied coverage for the procedure claiming the requested surgery isn't "medically necessary".
Many insurance claim denials are based upon something not being "medically necessary". How does an insurance adjuster determine if what our doctors suggest is medically necessary? Carolyn appealed the decision. HealthLink responded that a "doctor", also known as an "independent reviewer", determined the surgery wasn't necessary. Now, HealthLink says their decision is final. Healthlink has denied a potentially life-saving procedure for a woman they haven't met – I doubt they have even spoken with her doctors. Why? Carolyn's lawyer suspects that HealthLink hopes the delay will take so long that they can then shift the cost over to Medicare. I think the insurance claim denial attorney is right. So not only is HealthLink bullying Carolyn, but it is bullying the rest of us by pushing costs to the government.
I wish Carolyn and her attorney, Ken Vuylsteke, the best of luck and hope they are successful in exposing HealthLink's underlying motives.
Lindsay Rakers, Missouri injury attorney
UPDATE: Today, July 31, 2012, I received fantastic news from Deborah Wiethop at HealthLink. Ms. Wiethop informed me that Wilson's proposed surgery will now be pre-certified as medically appropriate. The letter sent to Ms. Wilson provides:
“During this federal review process, HealthLink re-evaluated your case and sought additional information from Dr. Schlaroff. In response to the additional information received and our confirmation that a documented jaw/facial bony abnormality is present, we have determined that the requested maxillomandibular advancement surgery meets our clinical guidelines and is medically appropriate. Thus, HealthLink HMO has updated our records to reflect pre-certification authorization for the proposed services. Based on this decision, we have withdrawn your appeal from the external review process.”
While it would have been most ideal to have had this pre-cert request handled properly the first time, I am encouraged and proud of HealthLink for doing the right thing. Thank you for the update Ms. Wiethop. I wish all of the best to Ms. Wilson and her upcoming procedure.