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Nonmesh hernia repair as medically justified

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  • Nonmesh hernia repair as medically justified

    My health insurance provider (the free insurance as i dont have work anymore because of this hernia) told me that in order to be covered by their insurance for a nonmesh hernia repair outside of where I live now, my primary physician should state to them that my nonmesh operation is medically justified, as against a repair with mesh. I am at a loss because how can you medically justify a nonmesh repair when most surgeons would say that mesh is okay, the reason why all the surgeons in my place are doing mesh repair for hernia. How can one medically justify a nonmesh repair? Who are better off with nonmesh repair as against hernia operation with mesh? What are the physical and health attributes or standards so that a patient can be declared as justified to get a nonmesh hernia repair? We only know something is wrong after an operation. So how can a doctor justify if a person is suited with mesh or with the traditional suture method? I hope somebody here can help clear the air. Thank you in advance.

  • #2
    It might come down to the surgeon and how hard they want to fight for you. They are the ones that submit the bills and sit on the panels and justify what they did. Ask your surgeon if what you heard is correct, to be sure. The people that man the phones at the insurance companies are often not really experts, and are just reading from a script.

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    • #3
      Fidel18,
      I hope that you can get the type of repair that you want and it will be covered! There are certain people that may not do well with mesh and have a higher chance of reaction or chronic pain - people with allergies, autoimmune disease, very thin. These are the few I can think of. There may be other reasons and hopefully someone will chime in and help out. Are you seeking a non-mesh repair out of fear of chronic pain? I donít blame you, thatís a great reason, as far as Iím concerned. Guess insurance company doesnít think so.
      Best wishes!

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      • #4
        fidel18 if you have an insurance with a limited network, the law is that they must cover medically necessary care for you. If they cannot provide that care by surgeons within your network, then the insurance must approve coverage for care to be provided by a surgeon outside your network. The surgeon must also agree to accept that referral.

        Indications for non-mesh tissue repair includes allergy to the mesh product itself, risk of reaction or chronic pain if mesh is implanted (Eg, very thin, autoimmune disorder, fibromyalgia, chronic pain, CVID, mast cell reaction syndrome).

        #ItsNotJustAHernia
        www.BeverlyHillsHerniaCenter.com

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        • #5
          drtowfigh Thank you. It's a tall order for me because I need my primary physician to be convinced that I am not suited for a mesh repair -- which all the surgeons do here -- in order for her to make the appropriate recommendation to my insurance's health plan and allow me to seek a nonmesh operation outside of my county. All the surgeons in the health plan's network are doing hernia repair with mesh. So how will i now prove to the health plan provider that not one of the surgeons in its network is "qualified" or "competent" to do my hernia repair, the reason why i am seeking someone outside of its network and county? The positive news is that this health plan provider can cover such services (nonmesh hernia repair) outside of its network and county if it is "medically justified." I prefer nonmesh repair but preference is not enough in order for my situation to be declared "medically justified." My PCP needs to justify it with my health plan provider. Thank you.

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          • #6
            Momof4 , Good intentions , Thank you for your inputs. Yes, fear of the life-changing complications, including chronic pain.

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            • #7
              fidel18 Have you discussed this specifically with your PCP doctor? Perhaps ask if they will fight the insurance battle on your behalf for what you feel is necessary for you? It's worth asking them. Share your concerns, do some research, make your case, be your own advocate.

              Do keep in mind that is increasingly difficult to find non-mesh hernia repairs in the USA, so depending on your location that could be a hurdle if there are no practitioners who are able to perform that procedure near you. It's also possible that it's not the ideal solution to your case or your hernia, particularly if you're obese where data shows the non-mesh repair is less effective.

              Anyway, good luck and keep us updated on your case and progress.

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              • #8
                I have yet to meet my PCP to ask her to recommend (justify) to my health plan to cover my operation outside of my county. The crucial thing is my PCP should be able to convince my health plan provider that my operation outside of my county is medically justified as there are no surgeons here who do non mesh. I have a chance for non mesh since im not obese. My only drawback is im in my 50s and stitch or suture is less effective (i dont know if this is really true). Thank you for your reply.

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                • #9
                  drtowfigh is interesting you mentioned "autoimmune disorder, fibromyalgia, chronic pain, CVID, mast cell reaction syndrome..."

                  Just after my mesh surgery (wich I've described in other posts), in addition to chronic pain, I've also started to suffer a myriade of rare symptoms. My new surgeon thinks iin a systemic foreign body reaction, but my internal medicine physician can't explain, such as pelvic burning, cold/burn pain and excessive sweeting in my feet, hands and both armpits, skin itching, abnormal corporal thermoregulation (high temp, very low temp) and pain in muscles and puntual scleroderma in different parts of my body.
                  The only alterations found in my blood test are: very high IgE (>500 KU/l) 5x above the limit, mild abnormal proteinogram, low albumin and gamma globulins, very low transferrin and literally 0.1% eosinophiles.

                  Could those symptoms and lab test elicit one of the disorders you describe? mast cell reaction syndrome, perhaps?
                  Mostly due my internal medicine doctors are not able to establish a correlation.

                  Thanks.

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                  • #10
                    We donít know enough about systemic reactions seen as a reaction to mesh implantations. What we do know is
                    a) itís rare and
                    b) no blood test has been shown to be diagnostic or consistently shown to be suggestive of such a syndrome.
                    #ItsNotJustAHernia
                    www.BeverlyHillsHerniaCenter.com

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                    • #11
                      Anyway, if the list that you provide mention a few disorders, it's proper to think that they in fact exist.

                      I'm not a doctor, of course, but an IgE with a value five times over the upper limit (>500 in my case) could be constitutive of some kind of allergic reaction or my body is treating against a foreign body, and I think IgE is very close related to mastocityc diseases. I know it could be due ambiental causes, but having a close cause and reaction such my mesh implant, maybe some kind of vinculus could be elicited.

                      Thanks a lot!

                      Comment

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