Lawyer question re IVIG

[Kiera]

Hi everyone,

Does anyone know, if and when IVIG becomes the standard treatment for pandas (presuming after the IVIG clinical trial shows it's effectiveness) and ins co.s can no longer deny it as experimental, do we have any recourse with the ins co. to backpay for IVIG we paid for OOP? Especially ones we appealed and got denied on the basis of experimental? Just wondering!

[beeskneesmommy]

I highly doubt it, but I would like to know also as we are heading into IVig out of pocket in a couple of weeks d/t Cigna denying twice...

[norcalmom]

no kidding. some cover it, some deny it. I'd even argue that many are being denied while some that apeal and appeal who may have a different doctor - and are using the same codes - are getting approved. I think its discrimination.

 

My case is a perfect example. My DS got IVIG (and we were told that he didn't require prior approval for that procedure) it was approved. fast forward 18 months. We were going to do another one. Same exact doctor, DX paper work - everything - except the admin office said that our insurance actually reads "pre-certification recommended" - this was not caught by last admin person. We thought that it would be a slam dunk - since they already approved it once - and they denied it! I'm gearing up my energy to make an appeal. This would be DS's 3rd IVIG. The first we paid out of pocket (different insurance) - and I appealed and it was a waste of my time. They make it so hard and time consuming.

 

Anyone have a "case manager" that has handled the appeals for them? What if we all got and found a person that could be a pandas "insurance expert" to make appeals for us? It certainly looks like if you know how to work the system and try hard enough you can get approval. Its like they count on you not appealing. Certain the nurse - who is just a general nurse - does not know more than my MD, PhD, Stanford pediatric immunologist that is asking for the procedure. It hasn't been "proven" according to the denial. Which is funny - since DS had one, and it worked for him last time (and you paid for it last time). You don't get more specific proof than that!

Edited September 5, 2012 by norcalmom

[norcalmom]

we need something like this...

http://www.onclive.com/media/pdf/79a5b105a9bda419c0b419fb1f7afab0.pdf

 

this is rare disease called Gaucher. Its very expensive to treat. And they have this groupd of insurance advocates around the country to asset you in making appeals when you are denied coverage...I found it when looking for some type of assistance with my appeal...which I am just starting...