is he doing the kneedle/knife procedure on your fistula? he has done 2 on my sinus that have not worked. He also thought maybe my sinus could be Crohns related but my surgeon believes it was my original issue from surgery #1 five years ago when i had a leak.I am just going to leave it be for now. Good luck fighting insurance on this procedure. i am still fighting Medical Mutual from my procedures in June and July.

I'm glad they scheduled things sooner than later. Please let us know what the results are and how out are doing.

He won't know until he does the endoscope. But I have medical mutual also thru my mother. What do they not cover? This makes me worried now.

they said procedure was not medically necessary.. huh?? exactly.. lol.. anyways paperwork and doctors letters have been going back and forth for 6 months now. we will see

That's just dumb I would have done the same thing lol but thanks for the heads up Bc we can be prepared if it becomes necessary.

poucho/danielle..what exactly is this "needle/knife" thing. Supposedly that is being tried at my next EUA with remzi and shen to get my chronic sinus and jpouch excision wound to get it do possibly start to heal. He said something about injecting doxycyline.. but what is the "needle/knife" part? I found a 2012 pubmed paper where he did this succesfully for a totally different kind of sinus tract. any info would be most appreciated.

I am not sure exactly what it is. I will know more the 15th of feb that's when I have my appt with Shen. And he will know that day if he's doing that procedure or approaching it differently. I am just as confused as you honestly.

I've had multiple scope procedures with Dr. Shen for treatment of a small blind abscess at my ileo-anal anastamosis (joint between J-pouch and intestinal cuff). My abscess was a complication of my first surgery. The needle knife is a tool that is attached to (or part of) the scope that he will use for the procedure. It is used to make small incisions. The goal in my case was to cut the small narrow channel abscess open little by little (multiple procedures) to eventually make it fully open to (and part of) the main j-pouch "compartment". Think of the abscess (or sinus) shape progression staring as narrow blind channel, to a more bell-shaped connection (wider at inlet), to, ultimately, become part of the pouch wall (see attached rough sketch). The reasoning behind this...the narrow tract/sinus can trap stool and cause inflammation and problems. Opening it fully to, and joining it with the pouch wall should keep stool from getting trapped, and intestinal mucosa should be able to flow freely over the scar tissue and protect the flesh as it does throughout the intestines. As I understand, the Dioxy injections are to promote scar tissue creation and healing.
The small amount of cutting each time did not cause me any additional pain. I saw no blood to speak of following any of the procedures, although they'll tell you there might be some. Overall, the procedures are minimally invasive and do not typically yield a lot of side effects. (much better than having a surgery to fix things...) I would, however, feel a little "off" for a week or so after each procedure, very similar to the way I'd feel after simply having a 'normal' endoscope procedure. (Really, they're pumping lots of air into your intestines to take a look around, so that produces more abdominal tenderness than cutting with the needle knife...) Hopefully, I've explained this well enough and not made it more confusing. Let me know if you have any questions, and I can try to clear them up.

Regarding insurance claims, my experience is similar to others here. My insurance company has denied multiple claims (over the past two years) and asked Dr.Shen's office for more info, but apparently has not gotten the response they wanted. The denials have been due to "incorrect procedure coding". According to the ins. company, the doctor's office is submitting as a "misc procedure" and the insurance company feels it should be coded as something else and denies the claim on this technicality...but I could also see where they might not want to cover this as it might be considered "experimental" by them. Still trying to sort this out...

Wish you the best of luck. Take Care!

Wow does this sound like brain surgery! Sounds like a complicated procedure.

I feel sorry for all of you with insurance or potential insurance problems. Every time I have something like this done the insurance company is contacted to see if I'm covered.

Occasionally a bill will be rejected but a phone call to the doctor's billing department telling them they used the wrong code clears it up. They resubmit with the correct code.

Please ask them to get pre-authorization. I am sure there is no special code for this specific procedure but it is way more than an enhanced pouch scope too.

It's a real thinking out of the box procedure. They are probably saving the insurance company tons of money by not doing a major surgery instead, like a reversal.

screamin.. thanks for the detailed info and pics That describes better what I had read in the may2012 paper on the procedure. You could've been one of those cases they reported on! But doesn't seem like it clearly worked for you?

My situation is totally different. I no longer have a jpouch!!! But there is a sinus tract going up into the chronic unhealing wound where the jpouch was,. I am very confused as to the purpose of the needle/knife thing in my case. Especially since this will be done in an EUA where the surgeon will be doing yet another incision and drainage of the area, meaning he'll already be slicing me! All so confusing. But I suppose its worth a shot because nothing else is working.

Except now I have to figure out if the insurance will pay for this. Don't know how to do that in advance, when they can't really even describe the procedure. any ideas anyone?

You'd think the billing department at CC would know how to code it. I know you don't have Crohn's, but here is an interesting article about dealing with that non-healing wound:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780215/

Jan

screamin weasel,
thank you for sharing your experiences,i have an appt with dr shen in march,my problem is constant and unrelenting b/m;s 18-30 per day,tried ciporo,flagyl,tin cure of opium,and xiafin in addition to vsl#3 d/s will be seeing Dr Brian Bosworth at nyp on wednedsay 02/06/13 for follow up on pouchoscopy he did on me on 01/31/13.I really like Dr Bosworth a truly good GI hopefully results will shed light on this situation,trying to be positive and keep j-pouch but i beginning to sense the bag is in my future.Good Health to all

Please ask to speak to the billing department to see if anyone is obtaining pre-authorization ahead of time. If there isn't a unique code for it they need to call your insurance company and see how to code it for approval. The doctors leave that all to someone else, they don't worry about the money. I believe CC doctors are all paid a set salary, vs revenue raised, so they don't deal with billings They might indicate a code for something, and misc sounds reasonable for such surgeries and procedures. I like going to where billing problems are handled. You can also call your insurance company too. I'd call CC billing first.

Maybe there is a better code for operating on someone because of an infection that is not going away. More specific than "misc".

Sorry that's the accountant in me popping out. I use to audit hospitals.

I just want it to be the 15th so I know exactly what he's doing or wants to do. I'm tired of dealing with it

Well had my pre-op appointment today for my next EUA (#8 to be exact, but who is counting) for the chronic wound and I learned absolutely NOTHING more about this needle/knife thing with doxy. injection. Other than that they have never done it for anyone with an unhealed wound! Guess its just another dart throwing in a darkened room where they can't even see a dart board. I guess there's nothing to lose, but sure seems as not much to gain other.. than just yet another round of anesthesia and more time until they really figure out what to do with this chronic wound. When will all of this silliness stop?

danielle - here is the pubmed abstract I found about Dr. Shen doing this for sinus tracts as in the above poster, screamins.. , situation.
http://www.ncbi.nlm.nih.gov/pubmed/22390150

and TE I asked at pre-registration about the insurance and billing for it and they couldn't answer anything. So what might you suggest I do next? thx.

If it were me, I would tell them that I was not going to go forward until it was preapproved by the insurance provider. That should get them talking. I hate to say this Liz, but this is sounding sort of experimental. Have they exhausted the other available options? I am OK with experimental when other options have been tried and failed. That said, it does make sense, in that it opens the wound at the base, so that it can continue to drain more effectively, while it heals from the inside out. Plus, you get long acting antibiotics in there to prevent infection and stimulate healing.

Jan

So how do you find out if it is preapproved by the insurance? It is not like it is easy to get any doc or nurse to communicate with you at CC. Maybe TE can help me here about how to find out about preapproval? Guess I should be preparing myself to be spending my day on the phone and flinging it around the room in fury tomorrow.

and yes, I agree, it DEFINITELY seems experimental. I think the problem is.. seems they are out of options??? and obviously trying to avoid the biggee..plastic surgery with gracilis muscle thing. I am just at a loss. And I am in PAIN, can't work, and sick of being sick. And eleven months now since the huge jpouch excision surgery...and that is AFTER all the years of prior surgeries and jpouch failure.

On top of that. I am allergic to so many antibiotics.. including minocyline which is in the same family as doxy. And am very concerned that I will have some bad reaction to doxycycline, especially when injected straight in. And I still have no answer to that question from the docs/nurses re: allergic reactions.. and don't expect I will get one.

Can't even get them to speak to each other about the Imuran suggestion from my rheumy doc. Was thinking I need to give the head anesthesologist a note to pass to both docs during my EUA so they talk to each other and make a decision!!!

Very frustrating and upsetting day.. to say the least. And I won't even get into the disaster and frustration caused from another doc in another department for other painful and problematic medical problems ......

thanks for listening and responding jan. your guidance is so greatly appreciated. I can't thank you enough.

You can contact your insurance provider and ask them to keep you in the loop about approval and tell them that you do not want to be on the hook for bills.

This certainly will prolong things, but it looks like you are in it for the long haul anyway. No point in adding insult to injury by having huge bills that are denied by insurance to boot! You need to know in advance how this will be paid for, and it might change your opinion on how to proceed (or not).

Jan

Please don't say it is experimental when talking to your insurance company. They like to say experimental treatments are not covered.

Jan is correct in that you should call your insurance company to see if CC has sent anything in for pre-approval. You also need to call the billing department at CC. Doctors and nurses rarely know anything about that side of their business.

Well a few hours into it.. and here is what I've learned. My insurance doesn't require a pre-authorization for outpatient surgeries. So there is nothing on record about this upcoming EUA surgery. They told me I can make CC ask for a "pre-determination". Not really sure if this will be a true commitment of what the insurance will pay. does anyone know?

The billing dept. at CC has nothing to do with any of this. There is a pre-certification dept.. but they only deal with pre-authorizations not pre-determinations. But I finally found out that there is a financial counselor that works directly in the colorectal surgery office! Hoping she might be able to get this pre-determination thing to my insurance company and figure out if the insurance will pay for this "experimental" procedure and two docs in an operating room.

poucho... I will send you her name if she is of any value to me.

Way to cut through the red tape

No one ever want's to commit to anything but I'd say a pre-determination will give you a good idea what they will and will not cover.

Seems like a good plan. But, as said before, don't be talking about "experimental" or "unproven." Those are just triggers to get the whole thing dumped into the declined bin. Focus on "recommended by primary treating physician" and "conservative approach failure." That makes it clear that the simple plan has been tried.

Even though preauthorization is not done for outpatient procedures, it does not mean they will cover it in the end. That is why the predetermination sounds like a good way to go, so you are not surprised.

I hate having to deal with insurance companies and the non-medical bean counters that decide things. As imperfect as it is, I love my Kaiser HMO, because if they do it, it is covered...all self contained, like the Army!

Jan

thanks Liz

When he does the endoscope are you sedated or anything Bc I'm really nervous and afraid it will hurt with my fistula and everything. I hate tests.

danille. my situation is different as I will be in yet another EUA with Dr. Remzi. So I will be fully knocked out! I imagine if Dr. Shen is just doing this in the endoscopy clinic you will get the demerol/versed cocktail (like in a colonoscopy).. so you won't feel anything. And Dr. Shen is very very kind. He will not allow you to be in unusual pain. Trust me.

And I've made absolutely ZERO progress with the insurance situation. Other than the financial consultant in the colorectal dept saying.. oh it will be ok. You won't get another bill. Right.. like I believe that. So I have no clue what to do now about this. I have names of people but no one seems to know what to do and doesn't really give a darn.

I have an EUA scheduled with remzi in march and yeah my appt says endoscopy. I'm
Nervous Bc I don't know what to expect and I'm in pain right now. And worried it will just get worse.

The endoscopy isn't too bad, no prep. They give me conscious medication and the flex tube is similar to a colonscopy one and the doctor can see what's going on. I was diagnosed with GERD this way and have had to have my esophagus dilated twice.