ICD-9 Code: ‘6253’ Diagnosis: A lesson in Health Insurance

This is a very long-winded post.  You have been warned J


I am really counting my lucky stars today that in my adult life (which for purposes of this discussion started when I graduated from college and got a job…and my own insurance), I have had very few health issues. Health insurance has always seemed like this completely confusing thing that is really overwhelming, and that I will NEVER understand. I will never forget being 23 years old at the first day of my first big girl job and being sent home with a huge stack of books. From these I was to pick out which health insurance plan I wanted. Well I picked WRONG because a few months later I found myself in the parking lot of some random lab crying my eyes out to my mom because I could not find a lab that would take my insurance. I have had hypothyroidism since I was born, which means on a yearly basis (if not more frequently) I have to get a blood test to confirm that my medication dosage is correct. Well this is a problem when your prescription is out of refills, and the only way to get the doctor to refill it is to get a blood test. How did this turn out you may be wondering? Well my mom called in a favor to our family doctor who wrote me a new prescription for 6 months without getting the blood test…..and I never found a lab to take that insurance. A few months later during the open enrollment I switched to a new plan. Since that traumatic incident I have really been insurance drama free…..until now.

What the aforementioned experience should have taught me, was to learn about health insurance coverage. BUT I was 23 and naive to real life. I did learn in the past few years that the particular insurance I had is not necessary bad, IF you live a reasonable distance away from one of their health care centers. At the time I would have had to drive several hours to get to one of their centers. These days I actually live a few minutes away from one of their hospitals, but I still would never elect to have that insurance just based on past experience (if I had another choice of course).

Lesson two on insurance I recently learned: you need to have a good understanding of what your plan covers, and how much out-of-pocket you could end up spending before the coverage kicks in (ie your deductible), and how much you will need to kick in after you have met your deductible.

My first fail was last March. My husband got a new job and we decided that I would go onto his insurance plan rather than getting my own insurance through my employer. This decision was purely made based on money, and by money I mean the amount that we would be paying for our coverage out of our paycheck. Stupid. Stupid. Stupid. He is required to have insurance through his employer (and cannot be on my plan) because he has a child he is required to insure as well. I did absolutely no research into what my plan covered vs what his plan covered. SOOO STUPID. As it turns out my employers insurance covers the diagnosis and treatment of infertility. His insurance doesn’t cover shit (as it relates to infertility). The difference in me paying for my own plan and being on his plan is roughly $60 pretax dollars per month. So from April to now, that would be $360 pretax more that we would have paid. Instead we have spent roughly 5k post tax on doctors’ appointments, tests, labs, surgery ect. All because we didn’t understand health insurance.

So fast forward to today…..my surgery is actually partially covered by my insurance, however it’s not without its complications. There are four claims currently in the queue for the surgery.

1. Pathologist: Claim paid, I owed roughly $20.

2. Surgery Center: Claim paid: I owed roughly $400

3. Anesthesiologist:  Claim on hold due to verification of pre-existing conditions

4.  Doctor:  Claim on hold for unknown reasons (Already had to prepay $700).

So I received a letter last Friday from my insurance company regarding claim #3, that was VERY confusing.  Question one, why would the first two claims be paid, but not this one.  I mean they are all for the SAME procedure right?!?!  The letter asked me to prove that I had received treatment for my supposed pre-existing condition ICD-9 Code: 6253.  I had no idea I had a “condition” until July.  It may have existed, but I certainly wasn’t being treated for it (whatever IT is).  Thank goodness for Google.  ICD-9 Code: ‘6253’ is the diagnosis for Dysmenorrhea.  Again, thank you Google…. Dysmenorrhea menstruation cramping that affects daily activities.   I love that the letter used a code to describe my diagnosis rather than actual words.  If not for Google I would have no idea what the code meant so how could I possibly provide the backup they were requesting?  Also, nowhere on the form is there a place for you to tell them that this condition was not previously diagnosed or treated.  So I called the number on my card and after a million voice prompts finally talked to a person.   He told me to simply find a blank spot on the form and write that my condition was not previously treated/diagnosed, and that apparently I can get a letter from my previous insurance company saying I have had coverage for 12 months prior which will void out the supposed waiting period for pre-existing condition coverage. And another lesson learned…apparently insurance companies can refuse to cover pre-existing conditions for up to a year if you didn’t have coverage before.  WHAT!?  I mean this isn’t an issue for me because I have had health insurance my entire life, but that seems so messed up!  Thankfully I was able to get this letter from my old insurance company really easily, but seriously why is this so complicated in general?

For my forth claim I have absolutely no idea what information they need.  The person from my insurance company wasn’t helpful either.  The claim notes also said that they had “requested the information from the provider over 90 days ago”.  Well my surgery was less than 30 days ago, and 90 days ago I didn’t even know I was having surgery…..WTH!?!  When this eventually gets sorted out I should actually get money back from what I prepaid.  Since I have more than met my deductible my plan now goes to 80/20 coverage, and $700 is less than 20% of the total bill.  So now I am just sitting here….exhausted from trying to figure all of this out, and really wishing I had never switched plans. 😦