An Out-of-Network Specialist Makes All the Difference

I initially went to Dr. Seckin, an endometriosis specialist to find out the likelihood that endometriosis could be causing the severe lower back and leg pain I experienced for years. I had just had robotic-assisted surgery to diagnose and remove endometriosis a few months earlier. I chose to consult Dr. Seckin because my first surgeon, who was an oncology specialist, and multiple gynecologists where I lived were unable to give me an answer to this. They could also not provide any further management options of the disease going forward. The only thing they said was “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.”

Reading Dr. Seckin’s book

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

The wrong specialist

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. He did perform excision surgery for endometriosis, so I went there for a consultation. He agreed that another surgery was necessary. However, he stated clearly that 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.

The appeal process

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.

I had provided them over eight pages explaining the persistence of my symptoms after my first surgery. Moreover, I had added 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. These 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 in endometriosis, and that they perform a peer-to-peer review with Dr. Seckin.

Both appeal denials I received completely disregarded everything I had submitted. They simply stated that nothing I submitted was from an in-network provider. They added that in-network providers were capable of providing treatment.

Surgery with Dr. Seckin

I opted to have surgery with Dr. Seckin and pay out-of-pocket. 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 since 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 that someone is taking my condition seriously. 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 specialist, despite what my insurance company claims.