Suzanne Welninski (Flynn) Medical Expenses

For the past three years, I have watched as my wife’s health has deteriorated. She has anemia that is associated with her medical condition and has dropped to a very unsafe weight. Medicare is refusing to pay for a potentially life-saving procedure that is needed to help correct the underlying health problem.

Sue had major abdominal surgery in July 2019, after which the incision became infected. The infected incision site never healed properly despite treatment and has resulted in a very large abdominal wall hernia, about 10 inches wide. We were sent to a surgical team at ECMC in Buffalo and had our first appointment with them in March of 2020 to talk about fixing the hernia, which at that time was small, probably less than 2 inches. In March of 2020….COVID pandemic lockdowns and shutdowns of surgeries began. So…we were put off many times over the past 3 years. Every time it looked like it was Sue’s turn and surgeries were starting again, things were put back on hold and no surgery could happen. Meanwhile, the hernia just keeps getting larger and larger.

At this point she can have the surgery, but because the opening is so huge the safest, most effective way to do the surgery is to relax all of the involved muscles with Botox several weeks before the surgery. This will make those muscles very stretchable so that the hole in her abdomen can be safely closed with minimal complications. But Medicare refuses to pay for the Botox procedure. If the surgeons did the traditional method of fixing the hernia there is a very real risk that the abdominal and chest cavity pressure would be too great and she would not be able to breathe on her own after surgery. Botox will make sure that the muscles can stretch enough to give room in her abdominal and chest cavities so that this risk is greatly reduced.

This is the real problem….Sue is on Medicare and Medicare is refusing to pay the additional cost of the Botox treatment. They will only pay for the old way of hernia repair. We appealed the decision with Independent Health and were rejected. Then we took the appeal to a Federal Administrative Law Judge for the highest level of appeal and were again rejected. We have contacted Senator Gillibrand, as have many friends and family on our behalf, and still have not been able to get Medicare to pay.

HERE IS THE KICKER: Medicare’s reason for not covering this potentially life-saving procedure is that there is NO CURRENT CODE in their system for billing it! The Federal Judge did not dispute that Botox was effective and safe…just that there is no code.

At this point, we are trying to find a way to pay out of pocket for the Botox, as well as for all the associated copays for CT scans, hospital stay and all the costs associated with rehab and recovery. We are very strapped at this point as both Sue and myself are on SSD and these costs are breaking us.

Any help you can give would be greatly appreciated.

Thank you!