Re: Blue Cross Blue Shield Denial of 3 appeals

[Guest guest]

I sent you an email. When you get a chance go through all of my recent posts.

" shirl.halpern " <shirl.halpern@...> wrote:

Since September I have been waiting for approval for Xolair and have

finally been rejected for the third time by BC/BS Illinois. I am

probably one of the most allergic people on earth and chemically

sensitive too. I am on Advair 500/50, Spiriva, Intal, Flonase,

Zaditor, Double Zyrtec and Benedryl, Sin gulair and 3.75 Pred. daily.

Because I am hypervigilant I have never had an ER trip, but avoid

exposures- so my life is very very limited.-I stay at home and wear a

huge Hepa mask when outside. My PFT is 87% because of all the meds and

BC I think is one of the only companies who use PFT below 80% as one

of the criteria-even though if I took less meds or went out more I

would would be dead -let alone having a sub-normal PFT! My doctor is

fed up with the work he has had to do. I am faced with going to the

state board of review . Anyone have any thoughts, experience with

BC/BS of Illinois, etc? Thanks!

---------------------------------

Be a better friend, newshound, and know-it-all with Mobile. Try it now.

[Guest guest]

I feel for you, but my guess is that your lung function will have

to diminish (which I guarantee you don't want to happen), to qualify

for Xolair. But, after I look through your meds, I am not sure why

you physician has you on daily pred.? It would seemingly help your

lung function, but is certaily not one of the criteria for Xolair.

If you went off of pred., stayed with the Advair and your functions

fell, then you would meet the criteria for Xolair.

This might not be of much consolation to you. The downside of

Xolair right now, and it seems for the forseeable future, is that it

is (will be) restricted to diseases caused by atopy, specifically

atopy caused by airborne allergens. So, the criteria of the FEV1

below 80% is specifically a marker of asthma and airway obstruction.

It is used by most insurance companies. The other criteria of total

IgE above 30 IU/ml, positive blood test of atleast one airborne

allergen and falling FEV1 despite use of inhaled corticosteroid is

also used by most insurance companies. There is a lot of flaw in all

of this in my personal opinion, but the drug was intended for

allergic asthma that is not well controlled. That 80% number is a

fairly reliable number that there is not chronic obstruction.

My case is a perfect example of the flaw in the criteria. My FEV1

fell from about 92% to 72% in a little over a year. I was in the

90th percentile for well over 20 years despite asthma since birth. I

was healthy as a humnan being could be....marathons, 25-30 miles a

week running and I have been on two 8,000 meter peaks. I was never

very symptomatic of allergies in those 20 years, except for

dermographism. Anyhoo, in June 06' I couldn't stop coughing,

scratching and itching, and had shortness of breath. All this

commenced on one given evening. That hasn't changed up to today.

One year later, my IgE went from 252-354, but with very limited

allergies (wheat, gluten, oak amd rye grass all moderate to

minimal). I also found out that I have Eosinophilic Esophagitis. So,

I met all the criteria easily, and yet there is no absolute proof

that my asthma or EE is controlled by allergies. Likely one day it

will be approved for EE as well, as there is more and more evidence

that EE is controlled through the allergic component of asthma. Yet,

here I sit on Xolair, where it has probably resolved all my allergic

symptoms, EXCEPT asthma. What the criteria fails to recognize is

that asthma isn't always caused by allergies, despite significant

atopy. So, I would get yourself off of meds that aren't required to

meet the criteria, and then see what happens to your lung functions.

>

> Since September I have been waiting for approval for Xolair and

have

> finally been rejected for the third time by BC/BS Illinois. I am

> probably one of the most allergic people on earth and chemically

> sensitive too. I am on Advair 500/50, Spiriva, Intal, Flonase,

> Zaditor, Double Zyrtec and Benedryl, Sin gulair and 3.75 Pred.

daily.

> Because I am hypervigilant I have never had an ER trip, but avoid

> exposures- so my life is very very limited.-I stay at home and

wear a

> huge Hepa mask when outside. My PFT is 87% because of all the meds

and

> BC I think is one of the only companies who use PFT below 80% as

one

> of the criteria-even though if I took less meds or went out more I

> would would be dead -let alone having a sub-normal PFT! My doctor

is

> fed up with the work he has had to do. I am faced with going to the

> state board of review . Anyone have any thoughts, experience with

> BC/BS of Illinois, etc? Thanks!

>

[Guest guest]

My FEV1 is 79.3% while ON Xolair and they are still denying me. BCBS will deny

coverage for this medication every chance they get. You just have to fight them

but the fight takes a long, long time.

billybaroo1958 <cajjz109@...> wrote: I

feel for you, but my guess is that your lung function will have

to diminish (which I guarantee you don't want to happen), to qualify

for Xolair. But, after I look through your meds, I am not sure why

you physician has you on daily pred.? It would seemingly help your

lung function, but is certaily not one of the criteria for Xolair.

If you went off of pred., stayed with the Advair and your functions

fell, then you would meet the criteria for Xolair.

This might not be of much consolation to you. The downside of

Xolair right now, and it seems for the forseeable future, is that it

is (will be) restricted to diseases caused by atopy, specifically

atopy caused by airborne allergens. So, the criteria of the FEV1

below 80% is specifically a marker of asthma and airway obstruction.

It is used by most insurance companies. The other criteria of total

IgE above 30 IU/ml, positive blood test of atleast one airborne

allergen and falling FEV1 despite use of inhaled corticosteroid is

also used by most insurance companies. There is a lot of flaw in all

of this in my personal opinion, but the drug was intended for

allergic asthma that is not well controlled. That 80% number is a

fairly reliable number that there is not chronic obstruction.

My case is a perfect example of the flaw in the criteria. My FEV1

fell from about 92% to 72% in a little over a year. I was in the

90th percentile for well over 20 years despite asthma since birth. I

was healthy as a humnan being could be....marathons, 25-30 miles a

week running and I have been on two 8,000 meter peaks. I was never

very symptomatic of allergies in those 20 years, except for

dermographism. Anyhoo, in June 06' I couldn't stop coughing,

scratching and itching, and had shortness of breath. All this

commenced on one given evening. That hasn't changed up to today.

One year later, my IgE went from 252-354, but with very limited

allergies (wheat, gluten, oak amd rye grass all moderate to

minimal). I also found out that I have Eosinophilic Esophagitis. So,

I met all the criteria easily, and yet there is no absolute proof

that my asthma or EE is controlled by allergies. Likely one day it

will be approved for EE as well, as there is more and more evidence

that EE is controlled through the allergic component of asthma. Yet,

here I sit on Xolair, where it has probably resolved all my allergic

symptoms, EXCEPT asthma. What the criteria fails to recognize is

that asthma isn't always caused by allergies, despite significant

atopy. So, I would get yourself off of meds that aren't required to

meet the criteria, and then see what happens to your lung functions.

>

> Since September I have been waiting for approval for Xolair and

have

> finally been rejected for the third time by BC/BS Illinois. I am

> probably one of the most allergic people on earth and chemically

> sensitive too. I am on Advair 500/50, Spiriva, Intal, Flonase,

> Zaditor, Double Zyrtec and Benedryl, Sin gulair and 3.75 Pred.

daily.

> Because I am hypervigilant I have never had an ER trip, but avoid

> exposures- so my life is very very limited.-I stay at home and

wear a

> huge Hepa mask when outside. My PFT is 87% because of all the meds

and

> BC I think is one of the only companies who use PFT below 80% as

one

> of the criteria-even though if I took less meds or went out more I

> would would be dead -let alone having a sub-normal PFT! My doctor

is

> fed up with the work he has had to do. I am faced with going to the

> state board of review . Anyone have any thoughts, experience with

> BC/BS of Illinois, etc? Thanks!

>

---------------------------------

Be a better friend, newshound, and know-it-all with Mobile. Try it now.