I mean, no pleasure allowed. Impotence is fine with AI. It doesn't feel a thing. And if you lose a lower limb you still have the upper half.

Steroid injections? Very common procedure. Not that I'd want it, but still.

and out of surgery for 10 years! Bastards!

Last month Because I’m avoiding surgery to replace my arthritic joint!

"Epidural" means it's injected into the spinal cord.

Unless the words don't mean what they usually mean.

My spouse is a naturalized citizen yet I’m concerned for him. We just don’t know if the orange monster is going to take it away.

Why this is being flagged (other than cost cutting) is another question. Is the treatment of dubious efficacy? We need one of our DU physicians to offer an opinion here.

Hurts like hell.

on the list. "Epidural steroid injections for pain management, excluding facet joint injections"

Have had them in numerous joints. Keep me keeping on.

a Sadist. She thought you should endure the pain God brought you. So when she "took care of the poor"... it was without pain medication.

Of denying up charges by Medicare advantage where the real fraud is at.

That's one of its downsides. Of course, in that case, the purpose isn't to save the government money, but rather to maximize profit from the enrollees.

Broadly speaking, most of the payments made to the "Medicare Advantage" health care providers are funded by the Medicare system, so CMS is still involved, but someone allowed them to have this program named by a marketing department ("advantage" = "better" ) instead of naming it something that would more accurately describe it to the consumer.

Yes, they are provided by private insurance, and they are crappy - and shouldn't be. But that doesn't change the reality that they are, in fact, Medicare plans.

That Medicare plans should only be non-profit.

Might I suggest alternative monikers:

“Profits for Shareholders Plan”
…or
“CEO Needs Another Yacht Plan”
…or
“Denial to Thee Means Profits for Me”

Edited for clarity

that is SOP for "Advantage"

The biggest scandal is insurance companies upcoding the patient’s treatment and getting extra money from the government.

in Medicare Advantage plans and seems to be the growing trend in healthcare in general.

Across the board as the determinative method for all such medical treatment decisions.

Last edited Sat Dec 27, 2025, 02:55 AM - Edit history (1)

Another needless layer of complexity which thwarts patient’s access to care. Which is the insurance company long game-get patients to become discouraged and forego the care they need. Gotta protect the profits uber alles..🤬

interfering with the doctor-patient relationship.

Medicare Advantage is a standard insurance policy (whose coverage is dictated by the Medicare program). They are permitted to impose third party interventions in the relationship (limited network, prior authorization, etc.). Medicare is **generally** not.

There is a limited preauthorization requirement under Medicare - things which often double as cosmetic (eyelid lifts, for example) and DME (e.g. limits on coverage - like continuous glucose monitors which are covered only for certain T2 diabetics).

AI prior approval may be a growing trend in INSURANCE - but it is not a growing trend in healthcare. Medicare is a special program which does not require pre-authorization at all (let alone by AI) except in very limited circumstances when there is a specific, narrow, risk that the procedure is not covered under Medicare. That is different from a third party determining that the medical benefots of a covered procedure are not economically warranted.

all the possible coverage options. Original Medicare is a coverage option, so my post was grammatically correct.

Insurance is a means to pay for healthcare; it is not healthcare.

Insurance schemes which insert bean counters (AI or not) in the decision-making element of the doctor-patient relationship, is growing. That's not health care - it is a limitation on access to healthcare (since most of us aren't made of money). Nor is it part of the Medicare model of care.

One of the key features of original Medicare is that if a procedure is covered by Medicare when used for medical purposes, the doctor is free to use their own assessment in determining whether to use it.

Under Medicare rules, there are very limited circumstances in which a doctor is required to submit a medical decision to a third party for review before carrying out the decision. Those are, almost exclusively, DME or procedures which serve dual purposes (cosmetic and medical). These are not.

and obtain treatments recommended by their doctors.

If they wanted to do their little experiment, they should have done it with AI plans, not Traditional Medicare.

People do not pay more for traditional Medicare. They do have a 20% copay if they don't have a supplemental policy.

and doctors and lab costs. But they choose Traditional Medicare (with Parts A and B) despite the higher cost because they aren't limited as to doctors and haven't been required to get prior authorization.

while encouraging it in Traditional.

They know how unpopular it is, so it appears they are trying to help push even more people into for profit Advantage plans -- by taking away what has been a significant benefit from Traditional plans: the lack of prior authorization.

im pretty sure we needed pre approval on that.

the only thing that really heals these diabetic ulcers is to stay off of them.

Upthread someone speculated this looked like some kind of "purification through pain" idea strapped into a policy. Pain and humiliation seem well-represented here. Thank goodness AI systems are notoriously empathetic...

elderly populations most common sources of pain management, IMHO. Rather than pain management the Government seeks to replace it with cost management, not to actually save money but to convince seniors to not rely on Gov't services. If seniors give up or turn to other quasi service providers then billionaires like Musk and Ellison get to keep more of their money from paying for those services through taxes. And the quasi service providers get to make a bunch of money while also denying service. How else could they afford all of the advertising and support of PACS that support politicians that voted for this.
Yeah, that sounds about right.

Wife is diabetic, sees the endocrinologist every 90 days, requires blood draw with full workup one week before. Previously, when her appointment was over, the doc would give us an order for the next visit. No more. Now, go in, doc orders blood work, down to the second floor, draw blood, go to lunch while blood work is being done, come back later in afternoon.

Ditto for our annual -- can't do blood work in advance -- show up, get order, go to lad, stick, sit and wait for results.

Get a new doctor, or learn the rules yourself and educate them. Doctors pay very little attention to how the visits are paid for and their offices often work by a generic set of rules that are the most restrictive. My sarcoma specialist told me an MRI for suspected sarcoma would be delayed because I needed pre-approval. That is wrong. Under standard insurance - yes. Under Medicar Advantage plans - yes. Under standard Medicare - no.

We've been fighting for a week to get sensors for my wife's continuous glucose monitors. They are covered under Part B, not part D, and they do need prior authorization (their use is only covered by Medicare if you are on insulin, or in a few other limited circumstances). The first doctor we saw realized that, and knew her office used a particular provider for their Medicare Advantage providers - and insisted she needed to send the prescription there. Wrong.

Then she apparently didn't do anything. We called back to the office - and they said they would send it to CVS. We had an extended conversation about Part B coverage v. Part D coverage. I thought they had it straightened out - but sure enough the prescription was sent this morning to CVS without the prior authorization required, and the insurance under Part D was denied - since Medicare doesn't cover it like a drug.

Meanwhile, she had her first appointment with an endocrinologist - he re-ordered all her meds (including ones she just refilled, and including her sensor). He was unaware of any pre-authorization requirements - even though CGMs should be part of his bread and butter as an endocrinologist.

We has similar issues for blood glucose test strips - it took a month to straighten out.

So **IF** you are no standard Medicare your doctor is flat out wrong. There is no pre-authorization requirement for bloodwork. Your doctor may not know the rules - OR - he may be imposing his office policy on you. (If you don't like that policy, find a different doctor - or find out why he wants a same-day draw. There may be a medical reason for it.) But don't accept it because he is telling you it is a Medicare requirement - learn the rules and protect yourself.

Medicare Advantage, on the other hand, is an insurance program. They are permitted to impose prior-authorizations not required by Medicare. They are permitted to limit your doctors to a small list of doctors or providers, etc. If you have that - it was your choice not to get the full benefits of Medicare.

We are effectively under contract to Kaiser Permanente to obtain ALL of our healthcare from KP.

Going outside for self-financed care of any kind could invalidate the contract.

Potential double whammy.

"Historically, traditional Medicare did not require prior authorization, but the new pilot program from the Centers for Medicare & Medicaid Services is adding this requirement for 17 services."

How screwed up is that?

They do run the Medicare supplement plans and the (so-called) Advantzge plans, but not Parts A and B, thank goodness. I'm sure they'd be running the whole thing tomorrow if Republicans had their way.

brought to you by the republican party.

And they'll make profits based on how much care they deny. And all this will be happening while the Federal govt has been moving to clamp down on prior authorizations mishandled by Advantage companies.

my doc decides, not a greed head third party.

Iʻd like to know who initiated this program!

Thanks for the information and all. Unreal. Just reading our DUers here and the impacts this would make to their lives is powerful.

Both my sisters routinely get steroid shots in their various joints (both are still a few years away from Medicare).

"The pilot will last six years. It begins on January 1, 2026, for those on traditional Medicare in Arizona, New Jersey, Ohio, Oklahoma, Texas and Washington."

I wonder how they decided which states were to be the guinea pigs. My condolences to all traditional Meducare recipients who live in one of those states.

It says this pilot plan is supposed to last 6 years. I hope it can be rescinded sooner than that once Democrats are back in power.

Post haste. 🤬

if

A lot of things, including Trump's obvious physical and cognitive decline, his ongoing loss of support, and the way Republlicans in Congress are abadoning ship right and left, are making me feel more optimistic than I have in a while. I am a long way from giving up hope!

I mean, who is going to cover the taxes your corpse will owe into eternity?

… but leaving it to AI to decide. Nothing can go wrong with it, eh?
I feel for all of you who benefit from those types of treatments.

FYI, this comment started out as

and ended up as

Diagnosis and treatment of impotence

Are they an "incontinence control device"?

Great. Just fucking great.

I've had ET for over 10 years. When I first got it, it was really bad. I could hardly feed myself without throwing food across the room. Forget about eating peas - LOL. It's gotten better over the years and right now I don't even take medication for it. Other people notice my hands shaking more than I do.

I looked into the DBS and found out I would have to shave my head. Call me vain, but as a woman who lost her mother to breast cancer, I'm not shaving my head until I have to have chemo, which is hopefully never. My shakey hands just aren't that bad.

In any case, I think they are probably making sure that medications have been tried first. I think that's fair.

I've been on meds for over 15 years for ET. Until recently, I was able to control it with meds, but they seemed to have reached their limit. My neurologist suggested that the next thing to try was DBS or even Focused Ultrasound. I've got a few years to go for Medicare to kick in. My insurance doesn't cover much so instead I'm currently on an ET drug trial that is somewhat helpful, but there are times when I have to just stop and either go into zen mode (which isn't easy for me) or have a glass of wine to stop the shakes.

I had an uncle with Parkinson's who had DBS. It was like night and day for him.

into the doctor patient relationship under original Medicare.

The Medicare program is designed to permit doctors to exercise their judgment, in consultation with their patients, for when covered procedures are required.

The solution - if a particular procedure should be excluded from Medicare - is to eliminate it as a covered procedure. Not to insert a third party speed bump in to the process.

One of these procedures is one I needed before I enrolled in Medicare. It was needed in connection with a very aggressive cancer. Had approval been required, it would have been denied. (I was under standard insurance at the time - and it was denied after the fact). Had the surgery been delayed while waiting for prior authorization, denial, and an appeal, the cancer (at that point doubling in 2-3 weeks) would likely have metastasized and I would be living with metastatic lung cancer or dead. And, yes, I'm in one of the states hit by this.

It is a travesty. Fortunately, it is only a few states and a few procedures. But it is the nose under the camel's tent to require prior authorization for procedures which are covered procedures under Medicare.

unless Congress says absolutely fucking NO!

The pilot testing is a divide and conquer tactic. Pick a few states, and a few procedures, so those impacted don't have much of a voice. And those not impacted can't be bothered to lend their voices to the chorus of "No!"

Most people - including far too many doctors - don't understand how Medicare works. I've been told by quite a few DU members that Medicare has similar pre-authorization requirements as standard insurance (not true). DU has at least one very vocal supporter of this pilot program.

Medicare becomes the "primary payer" and the FEHB plan is supposed to be the supplement.

and that was 15 years ago. If prior authorization had been required, it could have been months.

I was in surgery about a week after my diagnosis (there were was an earlier surgery which removed most of the lump - because they believed it was benign). So the surgery was to remove the remnant of a very aggressive cancer, which had been doubling every 2-3 weeks. Turns out the most aggressive portion was the deepest (which hadn't been removed), so it needed to be out quickly. Even without knowing the portion remaining was the most aggressive, the surgeon was annoyed that I wasn't able to have it out more quickly.

I also had to have an MRI before the surgery to make sure there weren't any skip tumors nearby that just weren't palpable yet. (This particular cancer skips over healthy tissue - the 1 cm margin is because at that distance they get about 98% of any cells/newly established tumors which have jumped over healthy tissue into nearby tissue).

They initially insisted I would need to wait 10 days for pre-approval for an MRI before scheduling surgery (I was on employee insurance at the time). When pressed on the matter, after speaking with a few different departments, I learned that the Cleveland Clinic had the ability to do their own pre-authorization for MRIs. So that wait disappeared.

Because the wound left was about 5" in diameter, and they needed to be positive they had not only all of the tumor, but a cm of cancer-free tissue around the tumor, it couldn't be permanently closed until after a 2-3 week period for pathological examination. Pre-authorization was not required for the skin substitute - BUT - it was denied by the insurance company after the fact (and approved on appeal a month or two later). The surgeon would not have done the surgery without a skin substitute for that period of time. Since it was denied after the fact, I have no reason to believe there would be any different result had the review been done in advance, or by a Medicare AI-bot, rather than a private insurance review. That would have imposed an even longer wait period prior to surgery.

My theoretical position about this new imposition wouldn't have been very different - but my personal experience with pre-authorization (generally) and with one of the products in this list gives me a very personal reason to be angry about it.

My diagnosis was 5 years and 22 days ago. I've been NED (no evidence of disease) for 5 years and 13 days. In about a week, I get to drop from semi-annual surveillance to check for lung metastasis to biannual surveillance for the next decade or so. (With this disease, the frequency of checks start at quarterly, then drop to semi-annual, then (usually) to annual for the rest of my life. In my case, I found the tumor early, so my doctor believes the chance of late metastasis will be near zero after 15 years of surveillance.

me ashamed. For profit medical care is automatically corrupt just like, for profit prisons, for profit medical care is inherently corrupt.

We should be covered for every damned thing that happens to our entire body, including our teeth, ears and eyes.

Need to be gone.

Now.