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Help Me Get Insurance Approval!


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#1 KarenL

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Posted 19 October 2007 - 07:57 AM

Hi all. I had the flolan (ileoprost) infusion last year, but now my new insurance is putting my doctor through the mill again. It's been through an appeal already and now into the second appeal. What's the big deal? Anyone have any really good ideas or information that could sway them? It got me through last winter and I'm so afraid of losing another finger tip!
Karen

#2 lizzie

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Posted 19 October 2007 - 11:17 AM

Hi Karen, I'm really sorry to hear you are having such trouble getting what has been shown to be an effective treatment for raynauds (and PH). Here in the UK it is a pretty routine treatment- I was in last week for 5 day infusion of Iloprost and will have them 3 monthly over winter/spring, it really does make a difference. Iloprost is also an unlicensed drug here but is available on a named patient basis and is widely used for those with scleroderma. I wish I had some advice for you - but as you are no doubt aware our health system in the UK is different in that in that we pay national insurance and the goverment provides the healthcare ( but they also have restrictions on what treament is available, but iloprost isn't usually a problem) It does seem very shortsighted of the insurers not to approve the treatment- although Iloprost is expensive , I'm sure in the long run it is probably cheaper to prevent problems than to treat them. Hope you are successful in getting the treatment you need
Lizzie

#3 lizzie

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Posted 19 October 2007 - 12:07 PM

Hi Karen, I've just had another thought. Is your insurance company aware of the Cochrane systematic review " Iloprost and Cisaprost for Raynauds phenomenon in progressive systemic sclerosis" by Pope et al. The Cochrane Collaboration systematic reviews are the highest level of evidence available and are regarded as the gold standard of evidence by health professionals and government policy makers internationally. The review on Iloprost has looked at the results of seven randomised trials and has concluded that Iloprost is effective in the treatment of Raynauds phenomenon secondary to scleroderma at decresaing the frequency and severity of attacks and preventing and healing digital ulcers. The reviews are available for anyone to access and download/printout. Perhaps you could show that to your insurers?
Just type Cochrane library into google and click on the link that says Cochrane library or Cochrane collaboration. You will see a search box at the top right hand side- type in Iloprost and it will come up with the review which you can download or printout.
Lizzie

#4 GocartMoz

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Posted 19 October 2007 - 03:15 PM

This is the lawyer in me speaking but I believe if they have approved and paid for it in the past, and your dr. says it is medically necessary, they have already waived any experimental argument. I would have your dr. write a letter defining the medical necessity of the treatment and also have a lawyer send a letter arguing they "waived" any experimental argument regarding the treatment and are "estopped" from refusing to pay. If you are successful your lawyer should be able to get his fees paid by the insurance company.

Dave in FL

#5 Gidget

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Posted 20 October 2007 - 04:39 AM

Dave is right. If they paid for it in the past, then the "experimental" argument does not hold any water anymore. However, you said it is a "new insurance" company. If this is the case, then depending on how your policy is written, you may not get to the point of being able to argue "medical necessity". The policy may be written to "exclude all experimental treatments", in which case it doesn't matter if it is a medical necessity. There are insurance laws. In Connecticut, if your company is a fully funded policy, then the insurance company cannot "hide" behind the argument of "experimental" as under Connecticut insurance law, medical necessity dictates that the insurance company must pay for the procedure if your company has fully funded plan. You can call your State's Attorney General or Health Care Advocate for more information on your state's particular insurance laws. Again, using Connecticut as an example this only applies to FULLY funded health insurance plans. If in Connecticut, you are with a company with a SELF funded health insurance plans, then the plan runs outside of the state's insurance laws. This basically means that even if you meet the medical necessity requirement, coverage can still be denied based on the procedure being deemed "experimental". When this happens, you do not have much legal standing under state law to force the company to pay for your health procedure. Your only recourse is to throw yourself at the mercy of your company and ask that they pay for the health procedure. In most self funded plans, the insurance company is just an administrator of the plan and the Company you work for is really paying for the health care up to a certain amount. As such, the Company you work for can tell the insurance company that they will cover the procedure. Your other recourse is to try to find out if the insurance company has ever covered the procedure for anyone else -- in which case -- they need to cover it for you or they are not applying the policy uniformly. As such, then, the experimental argument no longer holds any weight and it just becomes a medical necessity argument. In any event, you need to be sure to take advantage of all your appeals. As part of the appeals process, the insurance company's will come up with an expert that will give a reason for the denial. You need to make sure you get a copy of that report and also make sure that doctor is an expert in your condition ie. rheumatologist and not a General Practicioner. Also, it may be good if your doctor talks directly to the insurance company's expert as part of the appeal in order to make sure the expert understands both the procedure and your need. Good luck. I know it is frustrating. I was denied coverage for a SCT due to it being experimental. Hopefully the appeals will work out for you. Regards, Gidget

#6 Sweet

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Posted 20 October 2007 - 05:15 AM

Hi Karen,

I am so sorry you have to even spend energy on this. I believe Dave is right. (I really love this board and having so many experts here to help each other)

Please us posted.
Warm and gentle hugs,

Pamela
ISN Support Specialist
International Scleroderma Network (ISN)

#7 KarenL

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Posted 30 October 2007 - 09:40 AM

Thanks soooo much everyone. I have been absent here due to fighting this with all my might. My doctor is increible, he's been with me every step of the way. We have been through two levels of appeal, and both have been turned down. The problem is that we had different insurance last year, this will be the first time for THIS insurance company, Blue Cross/Shield. I am going to look up the cochrane info that lizzie reccommended and write my third letter of appeal. I even faxed them four entire studies, all positive. In their last rejection letter they said that "since the policy clearly states that expeimental drugs are not covered, flolan which is not approved by the FDA for raynaud's is not covered". Going by that statement sounds like an open and shut case...but I will try again.

Thank you too Gidget, for your lengthy response. I did sit in on the last panel, over the phone, they are in WA and I am in NY. I told them how I have already lost the tip of one finger and also that I cannot take most other meds because of my heart issues. They still said no. I will look into finding out if they ever covered anyone else. Any ideas on how to do this? And yes, my doctor has written many peer reviewed articles and is a major scleroderma expert. I LOVE him!! :D

Thanks again!
Karen

#8 Gidget

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Posted 01 November 2007 - 12:39 PM

Karen,
Good luck! I have Blue Cross/Blue Shield in CT. The best way to find out if they have covered anyone else is to use your doctors. office to see who else has the same RX and the same insurance. Maybe your doctor can recall doing the same appeal process for someone else. Under HIPPA laws, you cannot get the patient's info but you can certainly argue the point with BCBS.

The next step is to go to your Human Resource Dept of your employer and talk to whomever handles benefits. Your benefits person probably does not even know that experimental is excluded. When talking to your benefits person, be sure to tell them how the other insurance covered the drug. Ask your benefits person to contact their rep at the insurance company and discuss getting this drug covered. Unfortunately, many benefits people are just interested in keeping the benefits cost down or the same to the employee and do not realize that the insurance companies are adding more and more exclusions to the policy -- such as "experimental" which is a problem for anybody with an autoimmune disease as everything is "experimental".

Also, if they cannot get BCBS to budge, then ask the company to directly cover the drug. It sounds like your company's plan is self funded and administered by BCBS. As such, your company can agree to cover the drug in which case BCBS will not care as it will run outside the administration of the plan.

As you are in NY, I assume that there is a health care advocate you can contact as well. Again the issue will be if your state's insurance laws apply to self funded plans such as BCBS. If so, then the BCBS cannot "hide" behind the experimental argument as your state laws will require them to cover the drug if it is deemed a "medical necessity". If this is the case, ask your state's attorney general office to write a letter on your behalf to both your company and BCBS advising them that they need to revisit your claim. At this point, it is of course helpful to be able to tell your attorney general's office if the drug has been covered in the past for other people.

In the meantime, keep up your appeals. Hopefully you will get lucky. I have been through the experimental hoop with BCBS with regards to a SCT and it is not fun. It is soo frustrating as they deny your request but do not offer any other treatment plan.

Also, in working with BCBS, they refused to cover my Nexium. I had to try all the other similar drugs and say they were not working (which they were not) before they finally covered the Nexium. This is certainly frustrating. I am assuming that there is no other drug available that BCBS will cover that you can try and then go back to say it didn't work -- similar to my Nexium battle. They also will not cover Viagra for the Raynaud's as they consider it a "sexual aid". Don't even try to get that covered as you will turn 100 before they will have a discussion with you. Again, it all boils down to how your company has determined what your benefits with BCBS will be in their agreement with BCBS. In my case, my company agreed that Viagra was a sexual aid -- and hence the non-coverage. My company could just have easily have amended the agreement with BCBS for Viagra to allow for coverage relating to Raynaud's.

Best of luck. Gidget.

#9 KarenL

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Posted 05 November 2007 - 12:01 PM

Thanks again Gidget!

I will pursue the company aspect of your information. The appeal turn down letter actually did say it is my particular policy that prevents this...maybe...

I know you can't get Viagra, but have you tried to get Revatio? It is definitely approved for PAH and maybe for Raynaud's too. Check on it!

Unfortunately, I can't take either due to my heart issues. As my doctors are fond of saying I'm a complicated case, but aren't all of we sclero's?? Oh well, at least we have each other!
Peace
Karen