Insurance Coverage

[mama2alex]

We are moving in the direction of getting IVIG. One hurdle (of several) is to get our insurance to cover it. Has anyone had success? The insurance company's initial response to the diagnosis codes I was given is, of course, DENIED. I'd love any insight on how to push this through - getting the right codes, appealing, anything. I have no idea how it all works, but am determined to get coverage if possible.

[ShaesMom]

We are moving in the direction of getting IVIG. One hurdle (of several) is to get our insurance to cover it. Has anyone had success? The insurance company's initial response to the diagnosis codes I was given is, of course, DENIED. I'd love any insight on how to push this through - getting the right codes, appealing, anything. I have no idea how it all works, but am determined to get coverage if possible.

 

Jennifer,

 

I believe you said in a previous post that your child failed the Pneumococcal titers vaccine test but your doctor wanted to revax and test again (?). If you can get your doctor to use the code for CVID based on those titers results you should be able to get insurance to pay for the IVIG. 279.06 is the code.

 

I believe others have had luck also using a code that has to do with encephalitis. I'm sure someone will share those. In fact,I think it was FallingApart who had a post on it awhile back-about five weeks ago.

[mama2alex]

Thanks ShaesMom. We've been too nervous to vaccinate him in order to see what the titers do, but I know if it gave us a certain result we would get coverage. Dr. K felt like it was risky, but of course our pulmonologist thinks vaccines have no risks. It's a tough decision. I'd like to try to get covered without doing this. Just so afraid the vaccine would be too taxing on his immune system and he would end up with worse problems.

[ShaesMom]

Thanks ShaesMom. We've been too nervous to vaccinate him in order to see what the titers do, but I know if it gave us a certain result we would get coverage. Dr. K felt like it was risky, but of course our pulmonologist thinks vaccines have no risks. It's a tough decision. I'd like to try to get covered without doing this. Just so afraid the vaccine would be too taxing on his immune system and he would end up with worse problems.

 

 

Oh, please understand that I am no way encouraging you to do the vaccine. My daughter was able to get insurance approval for IVIG based on her titer results but she was NOT vaccinated with the Pneumovax. She received Prevnar from age 2-3 and her immuno did not feel she needed to be revaxed (she's now 7). So, I'm wondering if you can find a doctor to dx him with CVID based on those original results and try for insurance approval.

[Iowamom]

Thanks ShaesMom. We've been too nervous to vaccinate him in order to see what the titers do, but I know if it gave us a certain result we would get coverage. Dr. K felt like it was risky, but of course our pulmonologist thinks vaccines have no risks. It's a tough decision. I'd like to try to get covered without doing this. Just so afraid the vaccine would be too taxing on his immune system and he would end up with worse problems.

 

 

Oh, please understand that I am no way encouraging you to do the vaccine. My daughter was able to get insurance approval for IVIG based on her titer results but she was NOT vaccinated with the Pneumovax. She received Prevnar from age 2-3 and her immuno did not feel she needed to be revaxed (she's now 7). So, I'm wondering if you can find a doctor to dx him with CVID based on those original results and try for insurance approval.

 

Hi all!

We just rec'd word that we are approved through BCBS (Iowa) for IVIG with Dr. K. Waitng to hear a date. This was a surprise. Unfortunately, we have had to go out of network, so when everything is said & done, we are guessing 50% will be what we will end up paying. Every code he gave us flew. 279.04 autoimmune disease NOS- I am pretty sure's the dx. My husband had all the bazillion codes!

 

Hoping others get this good news, too.

 

Dawn

[mama2alex]

Thanks ShaesMom. We've been too nervous to vaccinate him in order to see what the titers do, but I know if it gave us a certain result we would get coverage. Dr. K felt like it was risky, but of course our pulmonologist thinks vaccines have no risks. It's a tough decision. I'd like to try to get covered without doing this. Just so afraid the vaccine would be too taxing on his immune system and he would end up with worse problems.

 

 

Oh, please understand that I am no way encouraging you to do the vaccine. My daughter was able to get insurance approval for IVIG based on her titer results but she was NOT vaccinated with the Pneumovax. She received Prevnar from age 2-3 and her immuno did not feel she needed to be revaxed (she's now 7). So, I'm wondering if you can find a doctor to dx him with CVID based on those original results and try for insurance approval.

 

Hi all!

We just rec'd word that we are approved through BCBS (Iowa) for IVIG with Dr. K. Waitng to hear a date. This was a surprise. Unfortunately, we have had to go out of network, so when everything is said & done, we are guessing 50% will be what we will end up paying. Every code he gave us flew. 279.04 autoimmune disease NOS- I am pretty sure's the dx. My husband had all the bazillion codes!

 

Hoping others get this good news, too.

 

Dawn

 

Dawn,

 

That's wonderful! Blue Cross seems to be pretty good about this. Even 50% is a lot of money. Thanks for sharing the code.

 

Best of luck with the IVIG!

[melanie]

Thanks ShaesMom. We've been too nervous to vaccinate him in order to see what the titers do, but I know if it gave us a certain result we would get coverage. Dr. K felt like it was risky, but of course our pulmonologist thinks vaccines have no risks. It's a tough decision. I'd like to try to get covered without doing this. Just so afraid the vaccine would be too taxing on his immune system and he would end up with worse problems.

 

 

Oh, please understand that I am no way encouraging you to do the vaccine. My daughter was able to get insurance approval for IVIG based on her titer results but she was NOT vaccinated with the Pneumovax. She received Prevnar from age 2-3 and her immuno did not feel she needed to be revaxed (she's now 7). So, I'm wondering if you can find a doctor to dx him with CVID based on those original results and try for insurance approval.

 

Hi all!

We just rec'd word that we are approved through BCBS (Iowa) for IVIG with Dr. K. Waitng to hear a date. This was a surprise. Unfortunately, we have had to go out of network, so when everything is said & done, we are guessing 50% will be what we will end up paying. Every code he gave us flew. 279.04 autoimmune disease NOS- I am pretty sure's the dx. My husband had all the bazillion codes!

 

Hoping others get this good news, too.

 

Dawn

 

Dawn,

 

That's wonderful! Blue Cross seems to be pretty good about this. Even 50% is a lot of money. Thanks for sharing the code.

 

Best of luck with the IVIG!

 

 

I have BCBS too they covered us i dont know what the md dxed for insurance

[ShaesMom]

BCBS is paying for all of ours after we meet the deductible of course.

[Iowamom]

BCBS is paying for all of ours after we meet the deductible of course.

 

The infectious disease doc at the Children's Hospital in Des Moines, who initially dx'ed our son's PANDAS, will not go along with the IVIG so we returned to Dr. K. With our out-of-pocket met, our cost would be $0 if we stayed in Iowa. This is the only guy that anyone knows of in central Iowa who is treating PANDAS patients. Unfortunately, he's behind. Bent on penicillin ALWAYS working. He wouldn't even back down when our son's strep titers continued to rise and behaviors spiralled on Bicillin injections!!! After researching I begged azith from our GP. BCBS said that we could try going to Iowa City (Medical School) and if no one there could treat him, then going to Chicago wouldn't be considered out-of-network. I'm exhausted with all we have been through. Not about to attempt locate another doc only to waste more precious time and still end up in Chicago.

 

It's all in the coding. Obviously, PANDAS is explicitly rejected. When I saw the pre-auth form, I thought there was going to be no way Dr. K was going to get Evan's dx to work with the diseases listed.

 

Hoping others get some insurance coverage, too. Dawn

[vinay]

hi.. you can find lots of info about Insurance companies and codes and the procedures you are looking for at the below link....HOpe it will be useful...

 

Insurance Info

[tpotter]

Also, read the terms of your insurance. They are supposed to cover encephalitis, and if the doctor writes a good letter it should go through (Dr. K. is experienced with that, too.) If they still deny you, call them immediately, quote the terms, and be prepared to keep calling back (the more you bug them, the more they want to get rid of you.)

 

Another thing I have done (twice), is I call the State Insurance Commission. They usually tell me I have to respond to the insurance company (they quote the rules I already know,) but then they also call the insurance company. Trust me, insurance companies don't like to get called by the State Insurance Commission. Both times, I got a call back immediately, and told what I was trying to get approved was approved!

 

That all being said, I am going to be in the same boat on Monday when I get the codes from Diane at Dr. K.'s office (one of my kids is scheduled for the beginning of July!) BTW: The Surgical Center at Dr. K's takes BCBS, and I was told that Dr. K. does, too! That does help (in-network is always easier to get approved.)

 

Let me know how it goes.

[7upMom]

I just got my denial letter from BCBS - They denied from Dr K for one of the days of the procedure ( they paid the other) and then the whole amount from Oakbrook - they gave Oakbrook 5 days to fill out a request for more information to determine if "experimental"

We are completely stuck on what we are supposed to do from here- we have no idea ) : whether to contact Oakbrook or Dr K or appeal or what to send or anything ) :

Did any of you who have had success with BCBS have this happen also? and what did you do?

[saidie10]

We are moving in the direction of getting IVIG. One hurdle (of several) is to get our insurance to cover it. Has anyone had success? The insurance company's initial response to the diagnosis codes I was given is, of course, DENIED. I'd love any insight on how to push this through - getting the right codes, appealing, anything. I have no idea how it all works, but am determined to get coverage if possible.

 

this is a great thread. VERY helpful! good luck to everyone trying to find coverage. we have United and they cover IVIG for PANDAS on one of our boys and BCBS on the other...wait and see what will happen with his if needed!