Insurance denial for botox

[TracyB7777]

Oh HM....this is sooooo not right! Your appeal was AWESOME!! I was so praying they would approve it. I'm sorry, I don't have any grand ideas, but it does sound like you are following all possible steps. You are an amazing woman!! Good luck!

Tracy

[Violet M]

HM, I feel your pain right now -- it's like reliving my own experience with an appeal. I wanted to comment on the level 2 appeal by phone where you argue your case by phone before a panel. Let me tell you, these people will not be friendly and if it's anything like I went through it's not a question and answer dialogue type phone conversation. It's a "you can state your case and then the phone call is over" type atmosphere. They did not ask questions or allow me to ask questions. I wish I had know that going in but I just wanted to warn you so you could have your little speech ready. There is no point in preparing a list of questions you want to have answered unless yours turns out to be completely different than mine.

I hate to say it but after spending hours and hours preparing an awesome appeal and collecting peer-reviewed literature, etc. in the end I had to pay for my own PNE surgery in France. After exhausting all appeals I even went to the independent reviewer level who conceded in writing that the TIR surgery was the appropriate surgery for my case due to pelvic instability BUT sided with the insurance company that it was experimental. There was nothing I could do -- state, dept. of labor, etc. -- no one would help.

I hope your experience ends up being more rewarding than mine. It was incredibly stressful and my heart goes out to you right now. Best wishes,

Violet

[HerMajesty]

Thanks Tracy & Violet

Violet I know we have only ever talked by computer but believe me I am the queen of stating my case in a concise and condemning little speech. I can be quite intimidating while only politely stating facts. So I guess I already do have a speech because I really had not been planning on letting anyone get a word in edgewise anyhow.
Really though I do think it is a lost cause because of the timing with the insurance change, I am going through the steps but not taking it too seriously because i do believe my best bet is to start fresh with the new insurance company and be a little more savvy this time. I do know people that are getting piriformis botox through insurance and I think the game is to put in an insurance code for piriformis injection as if steroid were being used, then buy my own vials of botox, in cahoots with the MD, pretty sure that is how the game should be played if it is to be won!

[HerMajesty]

Well what can I say today, except yay, and God is good and answers prayer in His own time
I found out the botox policy for United Healthcare, which is what we are being switched to...and they acknowledge that botox is a proven treatment for piriformis syndrome! Here is their policy:
https://www.unitedhealthcareonline.com/ ... policy.pdf
Hint to UHC patients: they do not acknowledge botox as proven for pelvic floor, BUT they achnowledge it for piriformis syndrome, anal sphincter spasm, and neurogenic bladder...meaning if you show their written policy to your Doc and play with your codes, you might be able to get botox coverage. Pelvic floor as a diagnosis seems to be an approval-killer.
I sent the UHC policy to Anthem as the last piece of evidence in my 2nd level appeal; I am going to do it even though I have no hope of getting the procedure in time if I win the appeal. I want to make a point for my fellow sisters & brothers in the chronic pain community. I am also going to share my original appeal I sent to Anthem, in case it helps anyone to use as a template, but will do so after I move to my other computer, I think that is where it is.
Even though my own butt is getting saved by Divine intervention (and you can see my other thread complaining about the insurance change, as evidence of my lack of faith and patience), I want Anthem to go down eventualy on this issue, and will provide what assistance i can!

[HerMajesty]

Botox appeal to anthem.pdf

(123.76 KiB) Downloaded 265 times

Here is my Anthem appeal, just the 11 pages of text, all 30 exhibits listed are either personal medical records, or are articles whose abstracts or other materials that I already linked to on this thread. The 1st part is mostly unique to me but I did towards the end provide I believe an excellent general case to prove their policy is based on outdated literature. And they have nerve to say it was last updated in 2011. Hope a piece of it is useful to someone at some point. Although my best advice until more literature is published, is definitely to locate the written botox policy of your insurance company 1st and go over with your Doc the best way to do the codes. Pelvic pain is a definite red flag to the insurance companies right now: but the peripherals that go along with pelvic pain, such as neurogenic bladder or anal sphincter spasm, could possibly be used as primary codes to get approval.

[nyt]

HerMajesty, what a tour de force putting this appeal together! Thank you for sharing this as a reference for any of us looking to get Botox approved by our insurance company. It is greatly appreciated.

[Violet M]

HM, this appeal is buried in page 9 of a thread. Would you consider starting a new topic and repost the appeal and then we can make it into a sticky? Thanks,

Violet

BTW, I'm happy for you that you will get your Botox paid for.

[HerMajesty]

Hi Violet, unfortunately all the references I used, plus many more that are potentially useful, are scattered throughout the 9 pages! Would it work for me to start a new, brief "sticky" thread referencing this one, and sticky this one right below it?
...we could use the new sticky to post up additional references as well as any additional insurance or disability appeals regarding PNE, that others have done and are willing to share.

[Violet M]

I'll just post a sticky with a link to this thread. Thanks.

Violet

[HerMajesty]

works 4 me