insurance appeal advice

[bigmighty]

IVIG coverage denied by Anthem. Any advice for our DS's insurance appeal, recommendations as to what to include, etc? Many thanks - Suzanne

[szcasey]

Here's Anthem's IVIG policy. Compare coverage with the reason for denial. https://www.anthem.com/medicalguidelines/va/f3/s9/t0/pw_ad081049.pdf

 

Also check with the billing department at your doctor's office to see how they can help.

 

I fought this year's ago... Went through appeals process and lost. Ended up going to the CT Insurance Commissioner and won. It was a long process and I had help from the doctor's office.

 

A lot has changed since we were denied coverage. If I had to fight it now, I'd fight for coverage for IVIG for PANDAS (CIGNA's IVIG policy specifically mentions PANDAS as a non covered illness). I'd also question why there isn't a consistent IVIG policy for each insurance company. I'd also question why Anthem covers IVIG for Toxic Shock Syndrome (caused by strep)... Yet there's no mention of PANDAS (which means it isn't covered). Check out how other insurance companies handle IVIG - all post them online - Google X company IVIG policy.

 

 

Document every conversation you have with the doctor's office and the insurance company. Good luck.

[szcasey]

Check out this article (re one of the IVIG brands, Privigen). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697917/#!po=10.7843

 

I'm sure you can find something in the article re IgG numbers that justifies IVIG therapy.

 

Find out which IVIG therapy is offered by the doctor and research it backward and forward. I'm certain you'll find a nugget to help your fight.

[szcasey]

Gah! Hit send too soon. Below is a link for the different IVIG brands available. I'm on my cell... Hoping it's the most current list.

 

http://www.medprorx.com/forms/MedProRx_IVIg_chart.pdf

 

Again, good luck!

[jan251]

Our BCBS website explicitly says they will not cover IVIg for PANDAS. (They will, however, cover PEX for PANDAS.)

 

Have you looked at whether there are diagnostic markers for an immune deficiency? Those are laid out on the BCBS website that I looked at. That is the angle that our immunologist is working on.

 

I don't know how different Anthem is from BCBS.

[bigmighty]

Many thanks for the insights. I am taking my time to craft this carefully.

[bigmighty]

Not getting anywhere finding insurance companies that cover IVIG for PANDAS. Are there any out there that are covering it for PANS rather than accompanying CVIDs?

[Sirena]

Suzanne,

Perhaps your child can qualify for Medicaid based on medical disability from the Pandas. Medicaid policies should (must) cover the treatment under the EPSDT benefit. When the commercial policies exclude it as their policy, it is really hard to win coverage. One other avenue is if you happen to have a policy from a self indemnified group like a state employee--then you have recourse through the employer-benefits office. State insurance commissioners may also prove helpful--especially if the policy claims the treatment is "experimental or investigational as the basis of denial. You can point to more recent research that validates. Our commercial coverage denied it but DS's secondary Medicaid came to the rescue. It still took a month but first dose was just this Monday. Hang in there. You might also look for alternative grants for medical fu ding for kids. There's a few out there that --compared with fighting insurance--might be a better use of your time.

[NancyD]

The first time my DD had low IGG levels we were approved quickly for immunodeficiency. But after that we used the dx Selective Antibody Deficiency and got approved for IVIG a few different times. And when our primary commercial insurance provider didn't cover DD's secondary insurance through Medicaid approved. Medicaid can be a lifesaver and well worth the added cost for kids with disabilities!

 

Have you tested anti-pneumococcal antibodies (14 serotypes)?