Insurance Denying Payment for Remicade Treatments

[Guest guest]

Hi Everyone,

I tend to lurk more than post because being a single mom with a full-time job,

combined with the fatigue of RA, doesn't give me a lot of free time. But I

could use some of the wonderful insight that this group has right now.

After going back and forth with the clinic where I get my infusions several

times, my insurance company, Empire Blue Cross, has denied the claims for my

Remicade infusions. The person I got on the phone said that the doctor

reviewing the claims said it was not " medically necessary. "

I was diagnosed with RA in November 1999. I started on Plaquinil and NSAIDs.

After a few years, my flare ups started getting closer together, so I the

doctors added Methotrexate. Finally, last year, after adding Prednisone long

term rather than just sporadically during flare ups, my rheumatologist decided

that I needed a biologic to control the RA. Part of the decision was due to the

fact that I'd developed avascular necrosis in my right hip, so I was going to

have to ween off Prednisone.

I'm sure to all of you, that last paragraph sounded like a typical disease and

treatment progression. So I have no idea why the idiots at my insurance company

can't see that.

If any of you have gone through something similar with your own insurance, can

you let me know how you appealed it. I really need to find a way to fight this,

because there are already over $20,000 in charges that have been denied. If I

don't win the appeal, I'll have to file bankruptcy. At least I'm poor enough

that I still qualify for a full discharge bankruptcy, but I'd rather not have to

do that. I've worked too hard to get my credit score into the " excellent "

range.