IVIG denied by BCBSNC

[MMC]

Well...we thought we were set to have both kids get IVIG at Georgetown next week. But BCBS (of NC) reviewed it further and denied the treatments. They went back and forth, stating it was approved w/o review, then stating it needed review, and they then approved with approval #'s and everything...then upon further review, they denied it. This was prescribed by Dr Latimer. Her office worked very hard with insurance and she even spoke with their medical reviewer today and all they would say is we could appeal, but is presently denied. They really jerked us around this week...stating if this would have been done this year, there would have been no approval cert needed...but that changed as of Jan 1, 2010.

 

We are not sure what to do at this point. We may start the appeal process. But, it is even discouraging to read the recent post "tics worse even after IVIG, no relief in sight!". Our kid's main issues are with tics...so not even sure if IVIG would help. Swedo's articles and Dr Latimer said this would help, at least some, so we were willing to try.

[melanie]

Well...we thought we were set to have both kids get IVIG at Georgetown next week. But BCBS (of NC) reviewed it further and denied the treatments. They went back and forth, stating it was approved w/o review, then stating it needed review, and they then approved with approval #'s and everything...then upon further review, they denied it. This was prescribed by Dr Latimer. Her office worked very hard with insurance and she even spoke with their medical reviewer today and all they would say is we could appeal, but is presently denied. They really jerked us around this week...stating if this would have been done this year, there would have been no approval cert needed...but that changed as of Jan 1, 2010.

 

We are not sure what to do at this point. We may start the appeal process. But, it is even discouraging to read the recent post "tics worse even after IVIG, no relief in sight!". Our kid's main issues are with tics...so not even sure if IVIG would help. Swedo's articles and Dr Latimer said this would help, at least some, so we were willing to try.

 

dId you go through the appeals process?

[Worried_Dad]

MMC, you totally have our sympathies. FYI: with BCBS, even when you're pre-approved, that doesn't mean much.

 

We got the diagnosis and approval codes for the IVIG (furnished by Dr. K) pre-approved by BCBS for round 1 in 2008. It took 8 months - and probably 50 phone calls - to get any reimbursement at all. The story changed every time I called (like being told after 5 months that I "just didn't understand how complex these medical billings are"). Are they kidding? If the rest of us took 8 months to process something that was pre-approved in any other line of work, we'd get canned for sure!

 

We had 2 more "pre-approved" rounds of IVIG this summer (June and July). Still have not received a penny of reimbursement. Pardon my cynicism, but it seems clear to me that insurance companies delay and deflect and deny as long as possible, knowing that a certain percentage of insureds will simply give up.

 

I HATE OUR HEALTHCARE SYSTEM!!!

 

Hope you have better luck on appeal. The key may be finding a diagnosis code that the insurance companies can't dismiss as "controversial."

[sf_mom]

MMC: As you may know, Dr.'s are forging new ground with treatment....... I will point out that sometimes IVIG is not necessary, sometime one round of IVIG is fine, sometimes several rounds or monthly IVIG are required. Some of us have also experimented (hate to use that word but its the truth) with IVIG and higher dose antibiotics. Our son who is 5 1/2 years old, was exposed to a resilient strain of strep and presented with mostly TICS mild OCD. We have done 2 rounds of IVIG and had him on both 250 m.g. & 500 m.g. of Azithromycin. Each time we raised the dose he became 98% back to normal on the higher dose (he is 45 pounds). After having done this 3/4 times now...... we are holding course with the higher dose. Thankfully, we have a Dr. in the family that felt it was fine...

 

I know this doesn't help with your insurance situation BUT wanted to mention the combo of IVIG/Higher Dose antibiotic, TIC presentation.... if you should move forward with IVIG.

 

-Wendy