Insurance denial for botox

HerMajesty · Post by **HerMajesty** » Thu Apr 28, 2011 5:20 am

Tracy, what botox procedure were you denied for? Some of the articles I located deal with the efficacy of botox as a pelvic pain treatment in general, but much of it deals with the piriformis in particular (both that it can be a source of pudendal nerve entrapment and that there is strong evidence that botox to the piriformis is beneficial for piriformis syndrome). If you were also denied for piriformis botox, girl i have got you covered 100% with the articles I already have. If you are waiting for other pelvic floor botox procedures, I have some pertinent articles but not as many.

HerMajesty · Post by **HerMajesty** » Thu Apr 28, 2011 6:13 am

donstore · Post by **donstore** » Thu Apr 28, 2011 7:41 am

HM and Tracy,
Following this thread with great interest. HM - Great legwork on the Botox research.You are one hard charger ! Have a feeling your info will some in handy when I get my own inevitable denial down the road. Tracy - Who is your insurance provider ? Let us know what you come up with when you get your appeal together.

Best Wishes.

Don

Lernica · Post by **Lernica** » Thu Apr 28, 2011 3:14 pm

Wow! I said it before and I'll say it again, HerMajesty: You're Awesome!!

TracyB7777 · Post by **TracyB7777** » Thu Apr 28, 2011 9:46 pm

Wowzer!! HerMajesty you are incredible!! My denial says: Botulinum Toxin type a per unit (J0585) denied "No evidence based date for efficacy; considered experimental therapy". I'll need to talk to Dr. HIbner's staff to find out exactly what they wrote in the pre-cert. Hopefully I can get a copy of that letter.

donstore, I work for a school district that is self-insuraed and is managed by AmeriBen. Verbally over the phone when I originally explained all this they said it would be covered no problem; however they have proven differently now.

I'll be writing my letter and attaching all sorts of documents to fight this. Something has to give soon!!

Thank you again HerMajesty!! You are awesome!!!

merrie · Post by **merrie** » Thu Apr 28, 2011 10:15 pm

FYI - For my insurance company - I put together a letter that says the use of botox for chronic pelvic pain is proven and not experimental as evidenced by the following studies and then I provide a list of the published studies including the date, title and author without attaching the actual publications and that seems to have worked. The list HerMajesty provided is excellent source from which to put such a letter together. Also for diagnosis - my dr has put muscle spasm as the primary code and then the PN and other diagnoses as secondary codes.

My understanding is that there are more and more studies being done on botox and chronic pain so hopefully in time this will no longer be an issue.

Good luck!!

Merrie

HerMajesty · Post by **HerMajesty** » Fri Apr 29, 2011 2:53 am

aaaawwwww you guys are so nice.

I want to send the abstracts just so that they get a big pile of papers. Doreen told me when they approved her it was finally like, "OK, OK, just don't fax us any more papers!" I think it helps to just overwhelm them.
What ticks me off is, betcha anything the same Anthem BC / BS Doc who denied my botox might reverse the decision on appeal when I send in all this documentation, but then he will turn around and send the next pelvic pain patient the same refusal stating there is no evidence that botox is a legitimate treatment for pelvic pain. Just to see if that person will jump through the hoops or give up

The squeaky wheel gets the grease for sure, I learned that young and it is a lesson that has served me well. But I hate all this game - playing. So busy at work, I don't even know how i will find the time to write this appeal. And sad to say, as much as Anthem BC / BS ticks me off they are the BEST insurance I have ever had. Doesn't say a lot for the industry

HerMajesty · Post by **HerMajesty** » Fri Apr 29, 2011 11:26 pm

For anyone with an Anthem , BC/BS related insurance, this is the policy under which they deny botox:

http://www.anthem.com/medicalpolicies/p ... 049843.htm

I noticed they do allow it for neurogenic bladder which I do have, but that was not the "code" it was submitted under. As far as Merrie's suggestion of using a muscle spasticity code, I don't think that would have worked with Anthem, but obviously Merrie's insurance has this on their "OK" list while Anthem does not. Lesson learned the hard way: If you want an unusual procedure, get the written policy for that procedure from you insurance company BEFORE the Doc submits the codes, and have them submit the codes that will get you approved.

donstore · Post by **donstore** » Fri Apr 29, 2011 11:54 pm

This is great advice. Approval from insurance for anything is all about the ICD-9 diagnosis codes. You can look them up on the internet.

Don

HerMajesty · Post by **HerMajesty** » Sat Apr 30, 2011 12:17 am

Don (or anyone),
Do you know whether only a Physician is authorized to request approval under a particular code? I plan to bring up my neurogenic bladder (with urodynamics report) in the appeal; and am wondering if I can explicitly request that they approve my botox procedure under the neurogenic bladder code, or if I can only request that they advise me whether or not resubmission by the Physician under that code would be approved.

Health Organization for Pudendal Education

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