Insurance Claims, Gap Exceptions, Appeals

[momaine]

I thought I'd update you guys on the process I've been through to get the insurnace company (United Healthcare) to cover Dr. Trifiletti, who is outside our coverage area. I filed what is called a Gap Exception becasue there are no qualified Pediatric Neurologists near us. It was actually accepted and we can visit him up to 6 times this year. Now that I have been approved for that, I have sent an appeal for our apt. in Dec. that was not covered and hopefully they will pay that.

 

I also have appealed the fact that they won't cover Augmenin XR and I included in that the fact that Moxatag is one option we are considering and it cost much more than the Augmentin XR. Hopefully they will see that it is in both of our best interests to allow covereage on that drug.

 

It was a long process to say the least. I was on the phone for over 2 hours and then had to write letters to boot. They have 30 days to respond.

 

Angela

[fuelforall]

I thought I'd update you guys on the process I've been through to get the insurnace company (United Healthcare) to cover Dr. Trifiletti, who is outside our coverage area. I filed what is called a Gap Exception becasue there are no qualified Pediatric Neurologists near us. It was actually accepted and we can visit him up to 6 times this year. Now that I have been approved for that, I have sent an appeal for our apt. in Dec. that was not covered and hopefully they will pay that.

 

I also have appealed the fact that they won't cover Augmenin XR and I included in that the fact that Moxatag is one option we are considering and it cost much more than the Augmentin XR. Hopefully they will see that it is in both of our best interests to allow covereage on that drug.

 

It was a long process to say the least. I was on the phone for over 2 hours and then had to write letters to boot. They have 30 days to respond.

 

Angela

Hi,Angela,

Good luck with this, keep us posted re Augmentin XR.

I would put in for IVIG now as it will take 30 days for them to respond.

I assume your child qualifies for this?

Michael

[momaine]

I thought I'd update you guys on the process I've been through to get the insurnace company (United Healthcare) to cover Dr. Trifiletti, who is outside our coverage area. I filed what is called a Gap Exception becasue there are no qualified Pediatric Neurologists near us. It was actually accepted and we can visit him up to 6 times this year. Now that I have been approved for that, I have sent an appeal for our apt. in Dec. that was not covered and hopefully they will pay that.

 

I also have appealed the fact that they won't cover Augmenin XR and I included in that the fact that Moxatag is one option we are considering and it cost much more than the Augmentin XR. Hopefully they will see that it is in both of our best interests to allow covereage on that drug.

 

It was a long process to say the least. I was on the phone for over 2 hours and then had to write letters to boot. They have 30 days to respond.

 

Angela

Hi,Angela,

Good luck with this, keep us posted re Augmentin XR.

I would put in for IVIG now as it will take 30 days for them to respond.

I assume your child qualifies for this?

Michael

 

Actually, I don't think she does. Her tests on her immune system came back normal. I've not ruled it out and if I have to eventually will pay out of pocket, if I can't get them to pay for it. (think loan from 401k or something) But since we've seen so much progress without it, I'll wait and see where that gets us. I'd like to win the lottery! I get sick just thinking about a 10k loan for something the won't even know for sure if it will help.

Angela

[fuelforall]

I thought I'd update you guys on the process I've been through to get the insurnace company (United Healthcare) to cover Dr. Trifiletti, who is outside our coverage area. I filed what is called a Gap Exception becasue there are no qualified Pediatric Neurologists near us. It was actually accepted and we can visit him up to 6 times this year. Now that I have been approved for that, I have sent an appeal for our apt. in Dec. that was not covered and hopefully they will pay that.

 

I also have appealed the fact that they won't cover Augmenin XR and I included in that the fact that Moxatag is one option we are considering and it cost much more than the Augmentin XR. Hopefully they will see that it is in both of our best interests to allow covereage on that drug.

 

It was a long process to say the least. I was on the phone for over 2 hours and then had to write letters to boot. They have 30 days to respond.

 

Angela

Hi,Angela,

Good luck with this, keep us posted re Augmentin XR.

I would put in for IVIG now as it will take 30 days for them to respond.

I assume your child qualifies for this?

Michael

 

Actually, I don't think she does. Her tests on her immune system came back normal. I've not ruled it out and if I have to eventually will pay out of pocket, if I can't get them to pay for it. (think loan from 401k or something) But since we've seen so much progress without it, I'll wait and see where that gets us. I'd like to win the lottery! I get sick just thinking about a 10k loan for something the won't even know for sure if it will help.

Angela

 

HAving PANDAS may be enough.

[momaine]

I thought I'd update you guys on the process I've been through to get the insurnace company (United Healthcare) to cover Dr. Trifiletti, who is outside our coverage area. I filed what is called a Gap Exception becasue there are no qualified Pediatric Neurologists near us. It was actually accepted and we can visit him up to 6 times this year. Now that I have been approved for that, I have sent an appeal for our apt. in Dec. that was not covered and hopefully they will pay that.

 

I also have appealed the fact that they won't cover Augmenin XR and I included in that the fact that Moxatag is one option we are considering and it cost much more than the Augmentin XR. Hopefully they will see that it is in both of our best interests to allow covereage on that drug.

 

It was a long process to say the least. I was on the phone for over 2 hours and then had to write letters to boot. They have 30 days to respond.

 

Angela

Hi,Angela,

Good luck with this, keep us posted re Augmentin XR.

I would put in for IVIG now as it will take 30 days for them to respond.

I assume your child qualifies for this?

Michael

 

 

Actually, I don't think she does. Her tests on her immune system came back normal. I've not ruled it out and if I have to eventually will pay out of pocket, if I can't get them to pay for it. (think loan from 401k or something) But since we've seen so much progress without it, I'll wait and see where that gets us. I'd like to win the lottery! I get sick just thinking about a 10k loan for something the won't even know for sure if it will help.

Angela

 

HAving PANDAS may be enough.

 

Is there actually a diagnosis (diagnostic code) for PANDAS? I know that on my dd's diagnosis, it is just listed as OCD and transient tic disorder. Do the doctors actually make a note that it is PANDAS?

[fuelforall]

Well, of course Dr T can do that in a letter of support. I have his and another doctor's letter.

[fuelforall]

Well, of course Dr T can do that in a letter of support. I have his and another doctor's letter.

[EAMom]

Peglem had a post a while back that said that United Healthcare does cover PANDAS. There are also some other posts on "alternate codes" that people have used to get coverage. Here's a thread on that. http://www.latitudes.org/forums/index.php?...73&hl=codes