Health Organization for Pudendal Education

Well, I've finally been in contact with my insurance company and their reason for denial is because the procedure is not FDA approved. Until I can prove FDA approval it doesn't matter how many appeals I file, they won't approve it. Back to square one. Not giving up...just very frustrated.

TracyB7777 wrote:Well, I've finally been in contact with my insurance company and their reason for denial is because the procedure is not FDA approved. Until I can prove FDA approval it doesn't matter how many appeals I file, they won't approve it. Back to square one. Not giving up...just very frustrated.

I guess they mean it is an "off label" use for the drug? Wow that is a really nasty tactic There are soooo many drugs with "off label" uses, it really severely limits your coverage. Have you had a look at the professional labelling for botox to see what it is approved for? probably next to nothing...I am curious, gonna check and see if I can find it online.
Did you take a look at your written insurance policy to see if there is really a clause in there stating that medications will never be covered for off-label uses?
Also, will they cover the surgical center, Doctor, etc if you buy your own vial of botox? That is the way I have heard many insurance companies are willing to do this, although not mine.
If I were in your shoes I would appeal it up through the chain of command anyhow. Must have been 15 years ago at least, I was watching "Oprah" and she proposed this principle: "Never accept a "no" from somebody that does not have the power to give you a "yes". I knew right away how true this was, since when I worked retail they told us right out in our training there were certain things we were not allowed to do, like give refunds without a receipt, but if the customer complained too much then call a manager and the manager has the option to over-ride. Squeaky wheel gets the grease. Ever since then, if anyone tells me "no" I ask to talk to a manager, then if the manager says "no" I ask to speak to the owner, if it's a chain of stores and the owner says "no" you know I'll be writing to Corporate Headquarters.
If there really is a written policy denying you this treatment, you would have to break through several levels of chain of command before even reaching a person with the flexibility to make an exception for you. If it were me I would be harassing the President of the company before giving up. Although, if they offered to cover the procedure but not the botox vial itself, I would leave well enough alone and pay for the vial. It's expensive but a fraction of the total costs involved.

There's a chart further down on this page listing what the drug is FDA approved for:
http://www.fda.gov/Drugs/DrugSafety/Pos ... 174949.htm
In other words almost nothing. For sure get a written copy of the policy on which the denial is based.

Alas, since I work for a school district the highest level of appeal is to our Insurance Advisory Committee. Just what I want to have to talk about in front of a board member, co-workers, etc. Cr#@!!! So not happy at the moment. First level says won't cover any part of the procedure since it's all focused on the botox. Isn't it lovely that I can be prescribed meds, currently oxcarbazapene (sp?) which is an anit-seizure med, but i'm using "off label" for nerve pain (which btw...NOT working) and I didn't need approval for that!

That you use another medication "off-label" is good news, it means there is no general, enforced policy against "off label" usage. So that gives you appeal room. I wonder if you could argue that appealing to the committee breaches your confidentiality, and demand some kind of "change of venue". Although it could be to your advantage, to appeal to a group of people who know they will actually have to look you in the face if they deny you.

HM,

You have some really good advice. You should be a lawyer! Tracy, I also think it's unacceptable for you to have to appeal a medical decision to your peers. Given the urgency of the matter, however, it probably isn't practical to ask for a different panel. Good luck with it, Tracy, we're all rootin' for ya!

Tracy,
At the hospital where I work, we are all bound by the HIPPA law which insures confidentiality of patient information with penalties for violating same. I'm not sure how this would work with an advisory committee of a self-insured school district but this must apply to them as well. But look at it this way.... you have a real problem with a genuine need for treatment. There is nothing to be ashamed about here. You deserve fair treatment as you would for any medical condition.
As HM says, maybe there is an advantage in making an appeal to people who know you instead of the faceless bean counters at the insurance company.

Best Wishes,

Don

Lernica wrote:HM,

You have some really good advice. You should be a lawyer!

Actually, after a career working as a nurse in the prisons and jails, I had in fact been accepted into a Bachelor's program in Criminal Justice, which I was considering using as a springboard to get into Law school. I self-represented for my husband after he was in a major auto accident and got the maximum payout for us; and did a lot of family court filing as a foster parent to teens on probation / parole. My family court experience led a couple of friends to enlist my help in self - filing for divorces (a tragedy, but if somebody is going to get divorced I would rather see them file a mutual petition without lawyers involved, so that they are not destroyed financially ). Anyway, PNE is really what sidelined me from that "second career" path. I recognize that while it's a major interest of mine it is not God's plan for my life. So an "armchair lawyer" is all I'll ever be

Well apparently THAT was a big excercise in nothing...Anthem played me good.

My Anthem "advocate" asked me to extend their time to review the appeal from the the 11th to the 15th "because it looks like you have so much good stuff in here and it deserves to be gone over thoroughly". So now today's the 15th and guess what, I was denied, which was a foregone conclusion and could have been told to me after a cursory review that would take 1 day, because NOW they tell me, for a first level appeal, they cannot do anything but see if the patient fits into their current written policy, and if they can't fit you in they have to deny you. In other words, a first level appeal means Anthem denies you for the exact same reason they denied you in the original denial letter. It's not an appeal at all.

They had no literature on the subject more recent than 2002, and I supplied them with research up through 2011, but they can't even look at that because they must follow the written policy which is based on the 2002 literature.

OK, so a second level appeal will be totally different, with me verbally representing myself via phone to a panel of my peers...but guess what, they have stalled just enough to screw me because a second level appeal must be done on a Wednesday at least 20 days after the 1st level denial, which brings us to July 6...and the city council is voting tonight to change our insurance effective probably July 1, maybe July 15. if we switch July 1 I am up a creek without a paddle, and if they switch July 15 I have about a chance in a million of my Doctor being able to get me in for the procedure on time.

So I asked the "advocate", if the Medical Director has no power to look beyond the erroneous written policy in a 1st level appeal, does he have that power when doing a peer to peer? Because if so i want one and i already submitted during my written appeal, why I should be able to speak to the Medical Director personally as a peer in spite of policy to the contrary. So she tells me, "Oh, peer-to-peer is for prior to the appeals process anyhow, it's against the rules to do one once the appeals process is started". So I say, "but he wouldn't speak to me beforehand because i am a member, which is why i wrote an argument into my appeals letter explaining why I should be able to act as my own advocate in a peer-to-peer" So begins the circular conversation of logic vs. policy.

Anyway, I have a call in waiting to be returned, to an Insurance Investigator with the State Insurance Board. I want to find out :
1. Is it legal to take 30 days to work on a so-called appeals process which is really identical in all aspects to the original denial?
2. If I follow through with the level 2 appeal even though my coverage runs out, will Anthem be required to pay retroactively due to the date the original pre-authorization request and / or initiation of appeals process?
3. Can I indeed be denied the right to speak to the Medical Director or anyone with any power to decide my case?

I think they managed to win this one on me, which could even be a blessing in disguise as i know of many people whose insurances have covered botox no problem as long as the patient pays for the vials themselves, which I am prepared to do. So maybe all i really need to get on with this show is an insurance change.

I'm totally disgusted though

Oh HM it's a disgrace! Almost as if they are making up jobs for themselves 'review the appeal indeed,'when time is of the essence and they know it! It's a lot of things actually but non of it printable in polite company.

HerMajesty wrote:

They had no literature on the subject more recent than 2002, and I supplied them with research up through 2011, but they can't even look at that because they must follow the written policy which is based on the 2002 literature.

I'm totally disgusted though

Me too!