IVIG insurance coverage

[thenmama]

xx

Edited March 26, 2013 by thenmama

[peglem]

I don't understand the team's interpretation....isn't PANDAS post infectious encephalitis?

[thenmama]

xx

Edited March 26, 2013 by thenmama

[rockytop]

THERE IS A "CODE" for PANDAS?

 

That is news, I think-

 

It might be worth it to go to your doc (out-of-network// out-of-pocket) & file with the CORRECT, TRUTHFUL code (post-inf encephalitis); then file and get reimbursed.

 

We are doing that this week.

 

You have got to do something soon- don't let PANDAS get ahead of you! it sounds like it maybe already & time sometimes can be our enemy in this.

 

Will your ins co pay for pex? That helped one of my daughters immensely, but it did not last at 100%, unfortunately.

Edited May 26, 2011 by rockytop

[nicklemama]

My DS's IVIG was coded post infect encephalitis. It was denied and we are currently working on an appeal. I'm not sure the code even matters much. They are set to deny.

[kimballot]

Hi all,

 

We've gotten our first rejection for IVIG and are starting to work on a case for medical need. If you are going for an immune deficiency (vs PANDAS or post-strep enceph) how low does the IgG level need to be to classify a deficiency? I have one IgG quant serum that is technically low-- but barely-- maybe only 8-10 points below range so I'm afraid it may not help. Her IgA and IgM were both low normal and IgM was at the high/top of normal range. We've never had the subclasses run- just quant. What are the other options? The infusion team who's trying to get the auth wouldn't use the post-strep encephalitis code b/c they said it would be fraud.

 

I'm scrambling to see if there's anything else we can use to justify the treatment, or bolster our case for medical need for the treatment as it's been ordered. Her history of infectious illness is extensive-- well over 40 infections, not to mention all the viral illnesses, significant allergies/asthma, and sepsis at 4 months (for which she needed transfusions). Anything in all that helpful in any way?

 

I'm basically just hoping for something--anything I can use-- because she's been really severe for a while and is not able to function normally. As her steroids are tapering she's been ramping up again, and the past few days have just been totally fraught. We can cover the cost of the first IVIG. But I'm not sure how we'd manage to do it more than once or twice if she required it so I want to really push on the insurance front before we do the first treatment in case she does need it again down the road-- don't want the precedent to be denial. We've already spent many many many thousands of dollars for our son's ABA and other Autism therapies and treatments (not covered by insurance) over the past few years so there's just not a lot left to squeeze. And now we're also starting down the PANDAS (eval) road with our ds-- who, since a recent URI, is exploding with OCD and separation anxiety, having urinary accidents again, and after a horrible incident this weekend can't even go out in public anymore. My panic about the treatment costs has increased considerably as I'm facing the possibility that we may have 2 PANDAS kids-- and who knows what treatments they may end up needing over time.

 

We're launching an attack from two sides. Our doc will do a peer to peer, and we're going to HR to ask them to get it covered (it's not a contractual exclusion and we think they actually fund their own plan, which means the insurance company only manages it-- doesn't own it- giving the employer the power to allow coverage for it).

 

Anyway, any tips people have on what labs or other medical documentation/reasons have helped them would be greatly appreciated!

 

TH

 

Your insurance company should have written guidelines for IVIG approval. Get a copy of the guidelines. Your daughter is slightly deficient in overall IgG. Get her blood drawn and tested for subclasses and also for the 14 s.pnuemoniae titers. She could be slightly deficient overall but still have a large deficiency in a subclass or in several of the S. Pneumoniae titers. That, coupled with her infection history, could help make a case.

 

Also, be sure to have documentation of her infection history... how many infections per year, and how much school has she missed over the past year due to infection (I believe insurance companies also look at impact on quality of life when determining coverage for mild deficiencies).

 

Finally, I believe IVIG only provides IgG antibodies - it does not elevate IGA, so the IGA levels are not a clear case.

[tpotter]

[

Finally, I believe IVIG only provides IgG antibodies - it does not elevate IGA, so the IGA levels are not a clear case.

 

Ditto, Kimballot.

 

But, if IgA is very low, you have to be careful about the type of IVIG you use.