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DS, 12, has no antibodies for strep, has been on antibiotics for over 18 months and still gets strep. Dr B wants IVIg every eight weeks for one year. His total IGg is below range, but not below 700. Physically, he is exhausted all the time, stiff in the major joints, has anxiety, rages, etc and has many allergies.

 

We could do a couple of IVIgs if we refinance our house and some cropland, but we could not make it to a year.

 

What is the next step for an appeal? We already have Kevin Flynn of Healthcare Advocates in our corner to help with an appeal.

 

Cobbie

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Quickie reply now because I'm a bit slammed... but if you look at my content, I've posted insurance tips in the past. It may be titled something like IVIG insurance success or something like that...

 

1st: find out what type of plan you have: is it a state-regulated HMO or a federal/ERISA regulated group or self-insured plan sponsored by your employer. Do you have a "summary plan description?" If so-- you should fall in the latter category. This is important because you'll need to know which set of regulations your plan is obliged to follow going into the appeals process.

 

2nd: What was the reason for the denial? What did notification of the denial give you for dx code, and rationale? What does your policy say specifically about the reason for denial? If it's experimental/investigational, you'll need to know how your plan defines that to know what you'll have to produce in order to overturn the decision. Is IVIG for PANDAS a contractual exclusion? If so, your odds drop considerably (but again, this may depend some on your specific plan, employer, etc.).

 

 

Huge important rule/tip # 1 with insurance: You'll have to step back from your parent mode/personal investment in the coverage decision when making your case. Emotional appeals, pleas to do what's right or best for your child, etc. will fail because emotional/personal responses don't drive the decision making process (and if there is a speck of humanity in medical management, it's likely repressed between the hours of 9 and 5) . Providing an exhaustive list of reasons the insurer should cover the treatment for your child won't win the appeal for you-- but giving them the one right reason they need to cover it will. So, if you want to win, it's a matter of gathering info, learning the rules and criteria, carefully scrutinizing the initial denial and rationale, and building a strategic, bulletproof case that demonstrates precisely why the insurer MUST cover the treatment per the terms of the policy. It doesn't hurt to have some dirt on them, either, so turn your critical eye on the case records. You'll want to order them right away so you can look at how your claim was handled from intake to the denial letter. Compare that to your policy terms and either state or federal regulations. Anything off? Look a little fishy? Something that did or did not happen inconsistent with what is supposed to happen? Ideal is going back to them with a rock solid case for coverage per plan/policy terms, with a little added incentive for them to do what ought be done the second time around...

 

Says I who won an appeal 5 months ago and is already neck deep in another insane insurance debacle...

 

I'll be on and off this week, but feel free to post specific questions and I'll get back to you as soon as I can.

Gotta run, but good luck!

 

TH

Edited by thenmama
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DS, 12, has no antibodies for strep, has been on antibiotics for over 18 months and still gets strep. Dr B wants IVIg every eight weeks for one year. His total IGg is below range, but not below 700. Physically, he is exhausted all the time, stiff in the major joints, has anxiety, rages, etc and has many allergies.

 

We could do a couple of IVIgs if we refinance our house and some cropland, but we could not make it to a year.

 

What is the next step for an appeal? We already have Kevin Flynn of Healthcare Advocates in our corner to help with an appeal.

 

Cobbie

 

Its been a while since I have been on but my son had 4 IVIG approved with Cigna. We didnt even have to appeal. We had a diagnosis of PANDAS. And also a code for general autoimmune disorder and I think encephally.

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