Insurance Appeal -- Advice? . . .

[Tenacity]

My son's treating specialist recommends a year of high-dose IVIG infusions every 4-6 weeks. But after covering one IVIG infusion and one plasmapheresis procedure -- both of which produced clear improvement, but improvement which was limited and unsustainable without further treatment -- our insurance company is denying further coverage. We are now preparing to pay for treatment ourselves and to commence an external appeal.

 

In an honest, fair world (Ha!), and in accordance with the insurance company's written procedural guidelines, we should be able to overturn this decision on external appeal. Our son is severely ill -- mute, unable to read/write, unable to attend school for over 16 months now. Three specialists have diagnosed him. Immunomodulatory treatments have proven helpful, and everything else under the sun has been tried and shown to be ineffective. And we have at least a couple pieces of medical literature supporting the treatment protocol of high-dose IVIG. But we live in Rochester, NY, where "they don't believe in PANDAS." And at this stage in the game we trust no one and nothing.

 

We want to give this appeal our best shot. Does anyone have any good advice for us? (I am poking around previous posts on this subject, but it's tricky sifting through everything.) Is there a useful thread about insurance appeals on the forum? What medical publications are most helpful? What arguments? Has anyone employed a medical advocate and found it helpful?

 

We'd be grateful for any tips!

 

Thanks!

 

Tenacity

[sf_mom]

Yes, we employed medical advocate and he was inexpensive 'comparative' to potential costs/attorney and he was extremely helpful. Kevin Flynn http://www.healthcareadvocates.com/president.html.

 

We won our battle.... it was none PANDAS issue.

Edited March 14, 2011 by SF Mom

[Tenacity]

Thank you for the tip, SF Mom! (I may contact you directly to learn more.)

 

Tenacity