Insurance denial for botox

[HerMajesty]

Now get this...anyone smart enough to answer this question?

-I wanted to find out if I am entitled to the service from anthem even if they no longer cover me, if i win the appeal, seeing as the prior authorization denial and appeals process started when they still did cover me. I also wanted to find out if the fake "first level appeal" is even legal or not.

-So, I called the NV State Insurance Board, and their investigator said while he can start to research this question if i file a complaint (and I will), his agency really has no "teeth" when dealing with group plans, their decisions are only binding with individual plans. For group plans, he suggested the Federal Dept. Of labor.

-Called Federal Dept. of labor and was told since my husband works for a city, it is not in their jurisdiction because they only regulate group plans under private employers. They were kind of clueless about who would handle group plans purchased by municipalities, but finally theorized it might be the Dept. of Health and Human Services.

-If it really IS DHHS, I cant figure out how to get ahold of a human being in that dept. to ask the question. Their phone menu is not navigable, seems like a lot of trouble to spend hours trying to find a way to communicate, only to find out they aren't the right Depatment, as the DOL person was very unsure.

SO HERE IS MY BIG DIFFICULT QUESTION: WHO REGULATES THE BEHAVIOR OF A GROUP HEALTH PLAN PURCHASED BY A MUNICIPALITY??????

Plan right now, I did email same question to the Anthem so-called "Advocate", and I will file with the State of NV as they seem to be a very responsive agency and might even be able to locate the appropriate regulatory body for me and forward my complaint along. Hope somebody knows the answer to my question

[donstore]

HM,
You can appeal but they can't consider anything after 2002 ? Unfucking believable ! When you make healthcare a business driven by profits, this is what you get. God bless you for fighting the good fight against the forces of darkness. May their greedy souls burn in the hellfire of eternal damnation. When I was a kid, my dad ,who grew up during the depression, used to tell me "Don, if there is ever going to be any democracy in this country, we have to take all the bankers out and stand them up against a wall and shoot them down like dogs". Since he was a law-abiding middle class professional, I knew he was kidding....... but not completely. Maybe it's time to include the insurance company executives in the list for the firing squad. Just a thought.

Don

[Celeste]

-If it really IS DHHS, I cant figure out how to get ahold of a human being in that dept. to ask the question. Their phone menu is not navigable, seems like a lot of trouble to spend hours trying to find a way to communicate, only to find out they aren't the right Depatment, as the DOL person was very unsure.

Does your local tv news have a "Seven on Your Side" advocate of some sort? Maybe the newspaper? Perhaps a state legislator would take on DHHS? Letter to the editor? Certified, registered mail sent to DHHS? Ask your governor to intervene? I'm just thinking of all the ways that you as an individual can turn up the heat and make yourself impossible to ignore.

[HerMajesty]

Don,
I hope they don't get shot or burn in hell Just maybe bedbugs or a yeast infection ???? Or better yet ...PUDENDAL NEURALGIA!

Celeste, we do have a "seven on your side" of some type (I think out here it's Channel 8, I don't watch TV), and yes there is plenty I could do but as I am spread so thin right now, what I really want is the practical thing to get my treatment going. Fact is, the City Council voted last night on our new insurance plan, but we haven't been informed yet who it is, and and for all I know, I might have much better luck just re-filing for the procedure with them.

The new insurance isn't a "better deal" for us, nothing is a better deal in this economy, but what they are doing is taking our free Anthem POS away and downgrading to a free HMO with another company, with option to buy into the new company's POS. The buy-in will be $300- $350 per month (there is no picking and choosing, my whole family will have to be on the POS even though I am the only one who needs it), so in that sense it's a worse deal. But the POS itself might be better...It's rumored to be United Healthcare which doesn't look bad from what I can tell. And I am told we have to buy the POS or my chances or getting tarlov cyst surgery if I need it, are practically nil.

So, I will continue the Anthem appeals process because the NV Insurance Board advised me to. My Anthem "Advocate" wrote me back and claimed as far is she knows my plan is under NV Insurance Board jurisdiction although she will have to research it further. If they are under the Nevada Board Jurisdiction, that is great, they are very helpful over there!

So right now I have 2 options to exhaust before going to the media, the Governor, etc etc: Second level Anthem appeal combined with insurance Board complaint so that they can make Anthem behave; or just saying "see ya!" to Anthem and getting the procedure covered under my new insurance. Hopefully one of these will work so I don't have to consume my life with trying to get proper care.

[HerMajesty]

Well imagine that, my Anthem "advocate" actually ADVOCATED for me and got the 20 day rule for 2nd level appeals waived; now I can do my 2nd level appeal on 6/29/11. Probably useless if we change insurance on July 1 but not if the city gives us 30 days' notice as they are SUPPOSED to. My Doctor will not schedule the procedure before an approval, but will be able to fit me in within a week if the procedure is approved. I am going to call them back too and beg them to waive that policy and schedule me for 6/30/11...maybe I can actually slide this one in! Long shot but hey we'll see!

[Celeste]

Well imagine that, my Anthem "advocate" actually ADVOCATED for me and got the 20 day rule for 2nd level appeals waived; now I can do my 2nd level appeal on 6/29/11. Probably useless if we change insurance on July 1 but not if the city gives us 30 days' notice as they are SUPPOSED to. My Doctor will not schedule the procedure before an approval, but will be able to fit me in within a week if the procedure is approved. I am going to call them back too and beg them to waive that policy and schedule me for 6/30/11...maybe I can actually slide this one in! Long shot but hey we'll see!

I totally get where you're coming from; I was able to get my surgery booked in Houston for June 30, the last day of my insurance calendar year. After all I'd spent getting to that point, I didn't want to start the clock on a fresh deductible by delaying it even one day into July!!!

Very happy to hear that things seems to be working out after all. My gut feeling is, medical problems aren't quite enough? We have to be raked over the coals financially????

[HerMajesty]

I really am starting to hope I will sneak through, my husband was not able to reach anyone who lasted through the entire City Council meeting last night, but there is so much drama going on right now it sounds like the insurance vote was probably postponed They have to give us SOME notice so my insurance might last a little into July, praise God!
As far as being raked over the coals financially, I am only fighting for insurance payment for the botox because it is the last item I need to rule out, before being absolutely sure I need the tarlov cyst surgery. I really do suspect the tarlov cysts more than the piriformis. So I am trying to save my $$$$; I WILL get that tarlov surgery if I need it, even if I have to pay totally out of pocket and go into debt to do it. To be cured is priceless. If I thought the botox would cure me, I would have poured my own money into it months ago. But I really think it is just something necessary to rule out, since it is a much more conservative option than neurosurgery.
If I become confident that a cure is within reach I can be raked over the financial coals ad nauseum, don't really care.

[HerMajesty]

Spoke too soon. Insurance change effective July 1, official notice...not the 30 days they are required to give, but all bets are off at the moment.

[nyt]

HerMajesty, I feel your pain with the insurance company. I ran into the same type of problem with my health insurance through the state when I needed to fight a denied claim payment. You can't complain to the state because they don't have oversight so I had to call the Department of Labor at the Federal level and they informed me, like you, because it is public and not private they couldn't help. So basically, like you, I was screwed trying to get any help resolving issues at the government level. My employer nor insurance company were helpful so I ended up having to pay the full shot for the bill.

[HerMajesty]

HerMajesty, I feel your pain with the insurance company. I ran into the same type of problem with my health insurance through the state when I needed to fight a denied claim payment. You can't complain to the state because they don't have oversight so I had to call the Department of Labor at the Federal level and they informed me, like you, because it is public and not private they couldn't help. So basically, like you, I was screwed trying to get any help resolving issues at the government level. My employer nor insurance company were helpful so I ended up having to pay the full shot for the bill.

A friend of mine with a disabled daughter, who has waaay too much experience fighting insurance battles, told me that the agency that should be overseeing this is indeed the Department of Health and Human Services. She said back when she needed to contact them, she left message after message until her call was returned. Unfortunately, they have redone their phone menu so that there is no option to reach even an answering machine, much less a human being. So, I will submit with the State of Nevada, and mention the possible jurisdiction of DHHS, because their investigator seemed very willing to forward my complaint to the jursidiction in charge if he cannot help personally. I assume a State entity would have more luck making a connection with DHHS thatn I would as an individual.

I have all my materials for the second level appeal and will proceed simultaneously with trying to get Anthem to pay, and trying to get my new insurer to pay. Maybe somebody will have to do so eventually