Insurance Coverage for IVIG

[kthomas]

Just received news from the case worker at Dr. I."s office that ds8's IVIG has been denied. I am in the process of writing an appeal and am using the ideas given by thenmama. She listed United Health Care, CIGNA, and Harvard Pilgrim as covering IVIG. I have been searching the web for documentation, but have not found where their plans show PANDAS and IVIG are covered. I would love some help in getting documentation for the appeal I am writing to BCBSTX. Thanks.

[nicklemama]

I don't believe UHC still covers PANDAS. I think they stopped this past Nov.

[thenmama]

The policies of those insurers covered immunomodulatory therapies for PANDAS at the time I wrote that (UHC and HP were covering IVIG and Cigna was covering PEX-- the point being all three were covering one of the two immunomod treatments proven effective in the first study). I know some have changed policies since (which really ought to be illegal since it's not like new evidence has come out against it!).

Canada covers it (theoretically-- and the policy works for your appeal, unfortunately I've seen a number of Canadians who were having trouble finding the docs to treat PANDAS, which effectively renders covered treatments inaccessible). I'd rely most heavily on the NIMH's website statement about the treatments for PANDAS now. Also, have your doc make a case that it's considered "standard of care" and try to get some other PANDAS/treating docs/peds to sign a letter to that effect to include with your appeal. Also, learn the laws for claims/appeals and your policy's specific medical policies, claims/appeals procedures, coverage guidelines, E/I criteria, etc. Then, go through the case records (get from insurer if you haven't already) and determine if the insurer adhered to the policy, gave the claim a "full and fair review" and did everything they were supposed to do and nothing they weren't supposed to do. If the coverage guideline says articles in peer reviewed lit are necessary to not be considered E/I-- look in the record to see if the insurer ever consulted any (Anthem never follows our plan terms, never consult anything but the 3 compendia sitting on their desks-- when they even bother to do that).

 

I just got the message you left for me about this and I'll reply to you shortly (just have to get the kiddos going on the day)

[kthomas]

Thank you thenmama for your reply. A lot has changed in the last couple of years. You have given me some good ideas to go on and I appreciate the work you have done on doing the research on peer reviewed journals. Thank you.

[thenmama]

No problem. But keep in mind-- much of the change over the past couple of years has been for the better. Other insurers' policies don't really have any weight in terms of making a good case for coverage, so if something was going to change, that's the one thing it's easiest to work around (but, outside of making our insurance cases it's awful for our community that other insurers have regressed and denied coverage for a treatment they clearly know is appropriate for our kids' condition). It only shows that other insurers realized they could get away with not paying. Everyone knows the insurance pros that make coverage guidelines aren't really experts (they're businessmen with medical degrees) and don't have the professional cred of the specialists and researchers in the field. Insurers would never include other insurers' policies in their criteria for proving something is not experimental/investigational. Since the time I wrote the appeal info you have, the NIMH's position has strengthened in its support for the treatment and I would put heavy emphasis on that. Use the NIMH web page (cite the link AND print and submit a copy with your appeal). Show how your child meets the conditions for IVIG in the NIMH's statement (meaning prove in your appeal that the treatment is warranted according to the NIMH criteria-- include what's been done in the process of dx'ing your child to determine it's PANDAS, not non-PANDAS OCD/tics, and any relevant info to support that. If your child has had IVIG before and it's worked-- get statements from doc to support that b/c NIMH specifically includes the info from the study showing it was not effective. for non-PANDAS/PANS children). The White Paper was also released and if there is anything relevant to your child's case, you can reference it. Also, I believe IOCDF may have some newer info and it's worth looking at that to see if it's worth including.

 

Also-- you really need to go point by point through your policy's specific coverage guidelines for IVIG and its Experimental Investigative criteria (do you have that? if not, get it asap). I can answer specific questions if you have any. Or, if you find links to your policy's info online, I could take a look for you.

 

Gotta run now-- but lmk if you need anything.