Insurance change of heart - Good news for a change

[Guest guest]

Well we spoke to the insurance company today and apparently the letter we got

yesterday was the INITIAL DENIAL of our first verbal appeal. Today our case

manager - who is wonderful and really cares about Clayton - called us to tell

us what the APPEALS PANEL's decision was - well here it is:

They have approved an initial 2 weeks stay at Kennedy Kreiger and have set

the following agenda for them to follow:

The First Week - KKI basically has free reign to run any test on Clayton as

the insurance company want a diagnosis - etiology for his feeding problems -

basically an idea whether his refusal to eat is all behavioral (probably not)

and why he is having problems. They want to determine if there is a metabolic

problem (which the insurance company docs also suspect) they want to know so

(and in the conversation the case manager said if they need to due a muscle

biopsy I assume that you will want to go to Atlanta - at least she knows that

is prepared for that very real possibility in the future) KKI in addition to

looking for a diagnosis for Clayton is to determine a treatment plan for him

- both for eating and other issues.

The second week the treatment plan is to be initiated with the plan to

transfer the treatment plan to an in-network provider out patient program

which in our case would be the children's seashore house which has a M-F five

day a week program. We are not actually opposed to this if Seashore House is

willing to work with our local GI doctor who is not affiliated

with Children;s Hospital (affiliated with St. Chris) and the GI docs at CHOP

have no say in Clayton's treatment (I have had a very bad experience with

some of the GI's at CHOP although I know Dr. Licarus is a good doc).

If KKI determines that it is necessary for Clayton and in Clayton's best

interests to stay longer at KKI they can go to my case manager and get it

pre-certified if the reasons are acceptable.

I spoke to them at KKI this afternoon - Dr. Katz was not in - BUT it looks

like we can be going down there as early as next Wednesday afternoon (they

actually said early Wednesday - BUT we have our genetic appointment Wednesday

morning and do not want to cancel that).

So that is some good news from me for a change.

BTW - Clayton still had a high fever this morning - over 103 but the blood

work - CBC with diff indicated that it was viral - not sepsis - so we will

wait another day or so. His fever did break a little this evening after a

bath - down to just 100.8 so hopefully he will rebound soon.

Thanks to all of you for the wonderful words of support and encouragement - I

really appreciate it.

Love,

Sharon

mommy to Jake (who will be 6 on 4-16) and fraternal twins (3/30/97) - Cole

-(nda) and Clayton (eosinophilic gastroenteritis, food allergies (milk, soy,

eggs, wheat), g-tube, Nissen, latex allergy, mild DD, undiagnosed neuro

issues, sleep problems, sensory integration disorder and now tremors and

suspected metabolic disorder or genetic disorder, WHEN WILL THIS END)