Insurance denial for botox

[donstore]

HM,
Only doctors can diagnose for insurance purposes. Ideally, your PCP will submit the codes that work for what you want. When I was appealing for my Lyrica, it was like tossing spaghetti at a wall... we just kept at it till something stuck.

Don

[HerMajesty]

**WHEW!** I FINALLY finished writing my Anthem appeal...it's 11 pages of written appeal with around 50 or 60 pages of attached documentation. I really think they won't know what hit 'em, in a good way
After I go through the process and get approved (and I WILL take it as far as it needs to go to get approved!), I will post it here. I don't want to post it prior, as i am paranoid about the fact that this is a public forum AND see no reason to post it unless it wins...who wants to see how to do a losing appeal??
However Tracy, or any of you who have been on this thread all along, if you need inspiration for your own appeal I can PM it to you. I really think it is going to get the job done. I am also just sooooo glad not to have it hanging over my head anymore

[TracyB7777]

Oh HerMajesty that is fantastic news!! I would love some inspiration!! I'm currently waiting for Hibner's office to send me a copy of what they filed for so that I'm appealing the correct thing. My prayers are with you, my fingers and toes are crossed (but not my legs...sorry! )

Tracy

[donstore]

HM,
Hopefully, they will give in after the first few pages. I have a feeling that those of us who follow you in the botox appeal process will be fortunate that you preceded us. Looking forward to reading the results of your hard work. Thanks in advance for sharing it with us. Win or lose, I know it will be a valuable resource. GOOD LUCK !

Don

[grace4me]

Hi everyone! I am a 31y.o/female with history of bladder exstrophy with closure, augmentation at age 9, reconstruction os sphincter muscle, and numerous related procedures for correction. I have self-cathed since age 9, with a rigid, stainless steel cath, due to sphincter reconstruction. Complete neurogenic bladder, no self voiding, only cathing every 4-6 hours. History of chronic kidney stones, chronic kidney and bladder infections, renal cholic and bladder, urethral, and uretal spasms. Diagnosed with chronic pain syndrome in 2007, after birth of my daughter. I have had urinary tract issues from birth, but chronically since age 16, and have been hospitalized 1O of 12 months, within the last four years since my daughter's birth, with chronic kidney infections,severe bladder spasming that causes renal colic, requiring iv antibiotics and iv pain medication. I have been to numerous doctors, across four states, hoping and praying for one that would attempt to tackle my "case"....from the University of Alabama at Birmingham, to Emory University in Georgia, to the Mayo Clinic in J'ville, Florida and now finally, to Vanderbilt, TN. I am from a small town in Alabama......I have tried every medication from lexapro and all the other antidepressants, sedatives, narcotic pain medications, bladder installation with antibiotics( gent. And neomycin, nightly), anti spasmodic, lyrica, neurontin, nerve blocks, peridium,cystex, Sanctura XR,prophylactic antibiotics trigger point injections, pain patches, lidiocaine patches.......you name it After finding an amazing doctor, Melissa Kaufman, who has finally spoken words I have prayed to hear....."there is something very wrong, you shouldn't be going thru all this pain,and...I am gonna figure out what it is, and how to treat/help (it) you!!!" Praise the LORD!! Long story-short....my bladder is chronically spasming, which is causing my ureters and kidney to spasm(renal colic), causing a never-ending cycle of pain, hospitalizations, and putting my life on hold for it!! Botox injections in my bladder.....I have BCBS primary, and Medicare(hospital).....and was DENIED!!! However, Dr Kaufman is writing a letter of appeal, And I also have a case manager at BCBS that can hopefully shed light on my history and all the "other" methods of treatment I have been through!!!! I am happily married, 6 years in June....and we have a beautiful, miraculous four year old daughter...and I was told I'd never be able to carry a baby!! I want to be the mommie I have worked so hard to become for the last four years!!! She deserves the best of me!!!! I have heard so many wonderful, things about botox injections for the bladder....I was all set to make the five hour drive to have pre op and then the outpatient procedure with the injections this past Tues, but got a call Friday at 4pm the BCBS had denied coverage for it?!?!?! Is there anything I can do, as a patient, to help get it appealed quickly, even if my doc is/has sent a letter of appeal?!?!? Thanks!

[HerMajesty]

Dear grace4me,

I am surprised they denied you and think it has great potential to be turned over on appeal because the BCBS policy on use of botox does recognize its value for urinary conditions. I posted their policy a page or 2 back but will repost here so you don't have to dig through everything:
http://www.anthem.com/medicalpolicies/p ... 049843.htm
Their denial was based on the fact that somehow they managed to fit you outside of the box of the things the above policy says is approvable. We can help you more if you have your denial letter. If so retype here the exact reason they gave for the denial, which will be a prargraph towards the beginning of the denial letter. We can match it up to what their policy says about botox for neurogenic bladder. That will pinpoint where you need to focus your counter-argument.
All the best to you. I would not be surprised if your Doctor's appeal is sufficient because as you will see in the policy BCBS DOES recognize urinary tract applications for botox.

[HerMajesty]

P.S regarding getting it appealed quickly - your Doctor (maybe you, too, not sure) can put in a request to expedite the appeal but I am not sure most of us qualify for that as our conditions are long term and chronic. An expedited appeal is usually for an immediate threat to life and health. Otherwise they still don't have long to decide, I think 30 days. Details of all that should have come with your rejection letter; there should be papers related to your appeal rights in the same envelope.

[grace4me]

Dear HM~

Thank you so much for your help. My denial letter stated the following:

Why You Got This Letter:
Your doctor asked us to decide if the following service is right for you:

Botox injections

We still need the following information to make our decision:

Does the member have a diagnosis of idiopathic detrusor overactivity?

The Decision:
We want to make sure this service is right for you. We already have the info you sent us, but we still need the details above. Because we did not have everything we needed, we are denying this service.
Your doctor should send us the info we still need. If we have it, we can reopen your request.


What Else Do I Need to Know??
This review is not required by your healthcare plan. The review is being provided as a courtesy to your doctor.

Is your doctor in your network? If he or she did not get prior authorization for your care, or the services are not right for you, you may not have to pay the charges$

If you signed
An Acknowledgment of Financial Resp. For the 0coist of Service form before you got care and if BCBS of TN doesn't give prior authorization, you mAy have to pay the charges. If you get serviced out of your network, your benefits may be reduced.

What Are My Options??

If this is an urgent care request, please call Customer Service at the number on your member I'd card.


**this is what the letter states! I also have a case manager at BCBS, is there anything she maybe able to do to help?? I have left her a message, but am going to call again today??????

Thanks so much HM

[grace4me]

PS- HM.....

I put in another call to my case manager.....hoping she returns my call before the weekend! I just googled "BCBS denial of botox for bladder spasms" and happened upon this page, and read all the posts under "insurance and botox injections"! I will keep you all in my prayers, and hope that you all will get approval as well!! Thank you so much for the advice, I will mentions the policy for BCBS and botox for bladder spasm/overactive bladder to my case manager....when I get to talk to her ) Chronic, untreated pain is a thief NO ONE should have to endure.... God Bless you all!!

grace4me

[HerMajesty]

That is not actually a denial, it is a request for more information. They have not yet figured out whether you meet the criteria according to the policy that I linked to above. Has your Doctor already sent out the additional info? If not, make sure they see the BCBS policy first, and that way they can answer the question in a way that will help your case not hurt it. Do NOT just tell them about the policy, print them out an actual copy or send them the link. I don't have time right now to reread the policy and see whether a diagnosis of idiopathic detrussor overactivity is good or bad for approval, but they want a "yes" or "no" answer and only reading the policy will tell you and your Doctor which is the right answer! I believe a "yes" is what will help you but you need to read it and make sure I'm right. There is a list of approvable diagnoses and you need to see if idiopathic detrussor overactivity is on that list. The "more info" has to be sent in promptly too: Not sure of exact time frame but I know the denial letters follow those request for info letters pretty quickly.
I have never had a case manager with BCBS, but they must be good for something, definitely call her and pick her brain. She can probably tell you the deadline for your Doc to respond to the information request, whether a response was received yet, and if not where it should be sent. That way you will know whether you need to lean on your Doctor to send a response in time.