IVIG approval for BCBS members?

[Iowadawn]

Any BCBS carriers--our Iowa BCBS ins is dragging their heels on approval of Evan's 3rd IVIG. We have others working on this for us. If you have rec'd approval on the autoimmune disease NOS dx. Could you PM me. Thanks in advance. Dawn

[melanie]

We Have BCBS NJ we do IV every 21 days at home.I dont know the DX code but he is immune deficient

 

Melanie

[tantrums]

Melanie - Im a NJ state employee (don't slay me LOL) My DS has a subclass deficiency and they will no way no how cover this. I have BCBS NJ Direct. Does your child have a primary deficiency or subclass? Our BCBS case manager and three doctors have been willing to go to bat for us, but they will NOT approve.

 

BCBS is huge, so their plans are all different, right?

[melanie]

Im also a NJ direct (teacher) Im covered I dont know the dx coverage I have to look

 

Melanie

[tantrums]

Ha - NJ teacher - you're worse than me - social worker We should have the same insurance though if I'm not mistaken.

[melanie]

Social worker for school or state.That can make you worse then me haha.But yet Im covered under NJ direct same insurance .My sister has NJ direct too .shes a SW for schools and my BFF is a social worker for the state and she has the same insurance as I do.

 

melanie

[tantrums]

DHS - Division of Developmental Disabilities. I USED to be a DYFS worker but couldn't hack it

 

I know they are sketchy with our insurance sometimes -what they cover and won't. I know they play games. That's why I'm very curious to see if others with our actual coverage have gotten this covered. Cadillac benefits - I think NOT!

[tpotter]

OK ladies...back to the question at hand

 

It was recommended to me previously not to use an NOS code. But, the truth is that you need to get a copy of your insurance plan's policies on use of IVIG (call them and ask them for it...they have to give it to you.) Then go through it with a fine tooth comb, and see what your doctor's are comfortable using.

 

My boys have a subclass deficiency, and it is clearly listed in their policies as accepting it. BUT, there were also contingencies to it. We had to prove that they were actually getting sick as a result of the deficiency. I got hold of our pediatrician's records for the past 1/2 year (could have gone for 1 year, but they only gave me the past 1/2 year,) and I made a chart showing how many times they had been in, what their diagnoses were (mostly strep and/or bacterial related), and the fact that they were put on more abx to treat it (I also mentioned at the end of my level 2 appeal, that using that much abx can cause resistance to abx, and that was another reason the insurance company had to approve IVIG tx.) BTW...they had 7 - 8 sick visits in just 1/2 a year each...that's huge! Also, in an attempt to prove how sick they constantly were, I pulled their school absence records. I happen to keep that stuff, and used the past 3 years for each. The minimum number of absences in the past 3 years for either of my boys was 12...the maximum was 32! All because of illness.

 

Also, I noticed that you've already had 2 IVIG's. Have you documented any changes as a result of the treatments? I now our insurance company requires that, as well.

 

We certainly fought hard, and even with the above information, we had to continue fighting. But, at least we had the law on our side.

 

So, all I can suggest is that you have to get a copy of the policies for your particular plan, and start with that. But, be very careful if you keep changing the dx code. We had to do that after this summer's fiasco where it was just flat out denied. Then when we got the actual dx of immune deficiency with blood tests to prove it, we felt comfortable changing the dx, but they did try to refuse thinking that we were just "fishing". You have to make sure you're backed up with proof of everything you're submitting.

 

Good luck.

[tantrums]

I think that's part of our problem - fishing Well we have so many diagnosis as well including TS and of course IVIG is proven NOT to work of TS. The immune subclass wasn't enough because we don't have a proven pattern of it causing illness in him. He used to get Croup up to 12 times a year but grew out of that, which became the pandas. Since getting pandas, DS doesn't get any other illnesses for the most part. But the insurance co doesn't seem to care that the illness is attacking his brain instead of his respiratory system. I'm sure if he had continued with croup, we would've had no problem.

 

I do know that BCBS actually has PANDAS as a clear exclusion on the policy for IVIG.