BCBS of Texas has denied coverage

[3boysmom]

Dr. B.'s office has been battling our BCBS of Texas for 6 weeks now - for Preapproval of IVIG. Our DS11 's tests have shown immune deficiencies and the codes the doctor listed are under the approved code list. However they are denying coverage anyway because they claim that we are not showing proof that other treatments have failed. WE DO NOT use PANDAS on any of the insurance requests because if you read their BCBS website, they literally have a section on PANDAS and why they do not cover it! We are getting an IVIG done anyway but with flight, car, hotel, and the fact that he is 11 years old so weighs 95 lbs (IVIG cost is by weight of the child) this trip on July 24-27 will be $12,000. and we are scheduled for one in Sept. and Nov. That means we will have paid $36,000. out of pocket in just a few short months! WOW-seriously

 

Not to sound cheap, but we also have 2 other boys fighting this illness and pay for antibiotics for all 3 each month and $150. a week in therapy and we have a $10,000 deductable that has already been met!

 

 

Help with suggestions please

Edited July 16, 2011 by 3boysmom

[cynditk]

OK, my guess would be that they want him to try a course of prophylactic antibiotics-that would be daily antibiotics to prevent infections- have you guys done this yet? How does him immune deficiency manifest? My son has one too, so I get it, my son has been treated for immune deficiency before he got diagnosed with PANDAS. Do you know what markers for immune deficiency showed up-what his official diagnosis is? And what testing did DR.B do?

 

 

 

 

 

Dr. B.'s office has been battling our BCBS of Texas for 6 weeks now - for Preapproval of IVIG. Our DS11 's tests have shown immune deficiencies and the codes the doctor listed are under the approved code list. However they are denying coverage anyway because they claim that we are not showing proof that other treatments have failed. WE DO NOT use PANDAS on any of the insurance requests because if you read their BCBS website, they literally have a section on PANDAS and why they do not cover it! We are getting an IVIG done anyway but with flight, car, hotel, and the fact that he is 11 years old so weighs 95 lbs (IVIG cost is by weight of the child) this trip on July 24-27 will be $12,000. and we are scheduled for one in Sept. and Nov. That means we will have paid $36,000. out of pocket in just a few short months! WOW-seriously

 

Not to sound cheap, but we also have 2 other boys fighting this illness and pay for antibiotics for all 3 each month and $150. a week in therapy and we have a $10,000 deductable that has already been met!

 

 

Help with suggestions please

[3boysmom]

He has been on Augmentin XR 1000 for a year and a half. I am not sure what the markers are but Dr. B. said that they are within what would be covered for immune deficiency. I am surprised that if our code is in their under approved codes that they could tell our doctor that his treatment plan is not O.K. Do they then come back with their ideas for treatment?...sorry, just being a smart a$$.

 

I was really wondering if there is some type of free insurace advocacy group to contact to help us fight for coverage?