Insurance denial for botox

[Celeste]

HM, I'm so pleased for your fortunate turn of events!!! How wonderful that you've shared your template as well. I have to say, it's thrilling to see good news here!

[HerMajesty]

HM, I'm so pleased for your fortunate turn of events!!! How wonderful that you've shared your template as well. I have to say, it's thrilling to see good news here!

Thanks! I know it will take 2 or 3 months total probably, wait til July 1 to roll around, make an appointment, put in for an approval, shedule procedure...but I finally have confidence it will get done

[donstore]

HM,
Great Job !

[donstore]

HM,
Glad things are looking up for you. Thanks for sharing your magnificent efforts here on the forum. I know it will prove to be an invaluable resource for all of us who have to fight it out with the insurance companies over this issue. As you said, it is so crucial to have a doctor who will work with you and submit the diagnosis codes that will fit the written policy of the insurance company. Since there are so few sure answers with this problem they might as well call it something that gets your treatment paid for.

All My Best,

Don

[HerMajesty]

WOO !!! Major Adrenalin rush after my 2nd level Anthem appeal!

I made my case in front of 3 laypeople, one employed and covered by Anthem, and 2 persons covered by Anthem and not employed by them. They were the voting members. My "advocate" was also there to state a summary of my case, some kind of phone moderator to run the proceedings, and the Medical Director who I FINALLY had pinned down in my sites although he officially had no role in the appeal or voting, but was only there to answer technical terms.

Not sure I did the best job presenting my case before the panel, as I knew it was futile since I have the insurance change pending in 2 days. Instead, I honed in on the Medical Director and grilled the piss out of him about why their Botox policy contains no literature on botox injection to the piriformis dated after 2002 although there is pertinent literature easily accessible dating from 2002 - 2010, and as to why pelvic floor is dismissed out of hand without a review of literature, although literature dated from 2003-2010 is readily available for review. The latest policy review was done 5/19/2011 and contains none of that literature although it was readily available, as I submitted it all before 5/19/2011. I stated that I was concerned not just for myself but for the whole chronic pain community and that I would like to know whether I could expect to obtain updates on any progress made in this matter. He actually had nerve to say, he would pass my literature along but since the last review was 5/19/2011, I should check back 6 weeks after 5/19/2012 to see if any changes in the policy had generated at the annual review (!!) I stated if that was their only mechanism, I would track the issue through a complaint to the Nevada Insurance Commisssion.. At that point, the moderator was like ""ma'am, I see you are very passionate but we are almost out of time and the panel is not bound by our policies in a 2nd level appeal anyhow".

By that time, I was all fired up so asked to address the panel again briefly and made a very brief impassioned plea for their approval of the procedure in my case. I was good, I get that way when I am fired up, but I am sure I only stated a fraction of my personal case because of my delight in having access to an MD involved in Anthem policy creation. The vote could go either way. I'm supposed to be informed within 24 hours. Hey, that part was pretty much just for fun, right ?

LISTEN UP, ANTHEM POLICY HOLDERS: MY STATE (NEVADA) IS POORLY REGULATED. SO POORLY REGULATED IN FACT, THEY DECIDE A TIE IN AN ELECTION BY SEEING WHO PICKS THE HIGH CARD FROM A DECK, I AM SERIOUS! YOUR STATE MAY HAVE TIGHTER REGULATIONS. IF ANTHEM'S CONDUCT IS NOT ILLEGAL IN MY STATE, THIS DOES NOT MEAN IT IS LEGAL IN YOUR STATE! ANYONE DENIED BOTOX THROUGH ANTHEM, I AM AVAILABLE TO HELP YOU OUT. LET'S HOLD THEM TO SOME STANDARD OF ACCOUNTABILITY.

Well, that was fun

[TracyB7777]

WOW!! Just...wow. I can not believe decisions on our medical health and wellbeing and quality of life are decided by a deck of freakin cards! You are an incredibly strong person!!!

[Violet M]

HM, was this all taking place by phone? You are lucky to have had 2 people insured by Anthem but not employed by them on the panel. I'm assuming that was so you would have some neutral parties on the panel? I don't remember any such thing when I had my appeal. Anyway, you made me laugh and I wish you luck.

[HerMajesty]

This time they are making me wait to receive the panel vote by mail, funny they got very cold to me after that telephone conversation, no more casual "yes" or "no" by email or phone.
We leave tomorrow for vacation, so I don't know how it went til I get my mail upon return. I'll let you know how it turned out.
I believe the makeup of the panel was in compliance with Nevada law.
If the outcome of this appeal REALLY meant anything to me in terms of health care, which it does not because of the insurance change, I would actually put in a complaint if the panel voted against me: The panel was allowed to ask me questions, the employee had none, the 1st non-employee had an intelligent medical question to ask, and the 2nd non-employee asked only, "I am just curious, what position does your husband work in for the city?". I answered this but felt it was wholly inappropriate because there are some VERY ugly politics going on in this city right now, and my bet is that the last guy's vote will be based solely on how he feels, pro or con, about the battle my husband's union is in at the moment. I feel like that is basically what the vote will come down to: what opinion the guy has about city politics as a participant or spectator. If I had refused to answer I would know I lost his vote right there: at least by answering I gave myself a 50-50 shot. I was only allowed to know his 1st name and he knows now my husband's profession and employer, my 1st and last name, probably my contact info, and everything nasty you ever wanted to know about my private parts. Hoo-Ray.
Fortunately I am leaving Anthem behind me, middle finger up in the rear view mirror LOL.

[helenlegs 11]

Happy Holidays HM, You have earned them for entertainment value and LOL contributions alone. I was always taught mirror, signal, manoeuvre when driving too, just passing by to wave you off

[Faith]

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!

HM,

I had UHC and had Botox with Hibner and it was denied. I am starting the appeal process. They billed it under diagnosis code 728.85 Spasm of Muscle. It doesn't mention pelvic floor or pelvic pain anywhere. It just says, "We have determined that chemodenervation of muscles; extremity(s) and/or trunk muscle(s) and Botox injections are not covered." It further says that these services are not eligible for coverage because my plan doesn't cover unproven procedures.

The piriformis is a muscle, so I am confused based on their written policy. Also is this drug policy you give a link to related to your specific policy with UHC or any policy?

Anyone have access to any peer-reviewed articles on treatment with botox not specific to the piriformis? i am not finding very many good ones.