An Out-of-Network Specialist Makes All the Difference

I read extensively about endometriosis in an attempt to gain my own answers about this condition, and one of the sources for this was Dr. Seckin’s book, which lead me to understand that robotic-assisted surgery does not completely remove the disease, and that advanced endometriosis can cause back and leg pain identical to the kind of pain I was experiencing,…

I initially went to Dr. Seckin to find out the likelihood that endometriosis could be causing the severe low back and leg pain I had been having for years. I had just had robotic-assisted surgery to diagnose and remove endometriosis a few months prior. I chose to consult Dr. Seckin because my first surgeon, who was an oncologist, and multiple gynecologists where I lived were unable to give me an answer to this, nor could they provide any further management options of the disease going forward, other than “we don’t handle endometriosis beyond surgery,” “we won’t worry about it until your pain returns,” and “you may need to have one ovary and your uterus removed eventually.”

I read extensively about endometriosis in an attempt to gain my own answers about this condition, and one of the sources for this was Dr. Seckin’s book, which lead me to understand that robotic-assisted surgery does not completely remove the disease, and that advanced endometriosis can cause back and leg pain identical to the kind of pain I was experiencing, leading me to become even more concerned with finding a doctor that could help me manage the condition.

My insurance company denied my initial pre-authorization request on the basis that there were two in-network providers that could provide treatment. One was not an endometriosis specialist, and he performed robotic-assisted surgery rather than excision. The other was a specialist in Boston who treated endometriosis along with other conditions, and he did perform excision surgery for endometriosis, so I went there for a consultation. He agreed another surgery was necessary, however, he stated clearly he did not remove the disease if it was on any vital organs, out of concern of causing damage to the organ. He also stated that if my pain persisted after surgery, he would refer me to a pain management doctor, as he was unable to prescribe narcotics.

In the months after this, I submitted two levels of appeal to my insurance company, both of which were denied. They were denied on the basis that I had not submitted anything from an in-network provider stating that my first surgery had not been successful, and that I had not submitted anything from an in-network provider that treatment with Dr. Seckin would be materially different from the treatment provided in-network. I had provided to them over eight pages explaining the persistence of my symptoms after my first surgery, the findings of the recent MRI, and the lack of assistance I had received from in-network providers. I also submitted excerpts from Dr. Seckin and other endometriosis specialists, emphasizing the importance of having treatment by an experienced endometriosis specialist that is willing and capable of removing the disease from all areas. I submitted journal articles from reputable sources which examined incomplete versus complete removal of the disease, and disease persistence versus disease recurrence. I emphasized Dr. Seckin’s experience with advanced-stage endometriosis in contrast to the in-network providers, neither of whom specialized solely in endometriosis. I requested my insurance company have my requests reviewed by a board-certified gynecologist with experience with endometriosis, and that they perform a peer-to-peer review with Dr. Seckin. Both appeal denials I received completely disregarded everything I had submitted, and simply stated that nothing submitted was from an in-network provider, and that there are in-network providers capable of providing treatment.

I opted to have surgery with Dr. Seckin and pay out-of-pocket, because I was certain that he was the best shot I had at complete removal of the disease, and relieving my back and leg pain, which significantly affected my ability to walk for two weeks out of the month.  It has been less than two months after my surgery with Dr. Seckin, and my pain level is the best it has been in over four years. This is also the first time in the last year that I feel my condition is being taken seriously, and I do not have to worry that it is not being managed properly. I am certain based on my experiences that I would not have received the same level of treatment from an in-network provider, despite what my insurance company claims.