Re: Getting your Insurance Provider to pay for Photoderm Treatments (Repeat Message)

[Guest guest]

Adam, I think what you did here is amazing. Thank you so much for

sharing it.

Patty

> Recently a few people have asked me for a copy of the message I

wrote a few months ago explaining how I got Blue Choice to pay for my

Photoderm treatments, so I figured I'd repost the message for some of

the newer members in the group. I wanna warn u all ahead of time

that its really long, and doesn't cover anything except getting

photoderm treatments covered by Insurance, so, if this topic doesn't

interest you, I suggest just movin' on to the next message.

>

> " Ok, i have tried writing this several times, and each time about 4

or 5 pages into the letter

> my comp crashes on me and I lose everything i have spent hours

writing. By now I cant even

> remember the names of everyone who wanted a copy of this letter so

Im just going to address

> it to everyone on the server and ask that if this topic is

unteresting to you to simply skip

> this message, because it is going to be LONG! I'm also sorry for

this not being exremely well-organized,

> i am trying to write this letter relatively fast. If you need more

details or clarification

> let me know and I will explain better, but its already 1 Am and I

dont wanna be up until 6

> but its about time I get this letter written!

>

>

> The first thing I did when trying to get Photoderm covered by my

insurance was call my insurance

> company (Blue choice). I called Member Services (the number is

listed on the bottom right

> hand corner of my insurance card). I told the man who answered the

phone why I was calling.

> I wanted to have Photoderm done on my cea and wanted to know

step by step what I had to

> do to get it covered. He lookd into his big book of what is

covered by Blue Choice and what

> is not. UVA and UVB intense pulsed light therapy (Photoderm) Is

covered only for the treatment

> of Psoriasis and for Bipolar disorder.

>

>

> So i told the man I wasnt satisfied and wanted to know what the

next step would be in trying

> to attain coverage. He told me that I would need to appeal, or go

up for medical review, or

> something. I'm a little hazy on what happened next, but I remember

my Dermatologist ended

> up calling Blue Choice for me. My Derm is Not too smart when it

comes to cea, but I think

> thats what I was supposed to do. He got me a referral. however I

had to pay for it. He began

> the appeal process by writing a letter for me to Blue Choice. He

was quite hesitant, saying

> " You will never get coverage, Photoderm is not approved for use of

cea, and besides, treating

> cea is a cosmetic procedure, Blue Choice doesn't cover cosmetic

procedures! " cea is

> a cosmetic problem?! This, coming from my dermatologist?! Great!

Well, For those of you

> who know me, you all know I'm a big wuss when it comes to standing

up for myself when a doctor

> or someone like that tells me something I know to be blatently

wrong or unprofessional. Well,

> for some reason I didn't take it that morning. I told him cea

is not a cosmetic problem,

> and that I was GOING to get this thing covered. And that I was

surprised as a dermatologist

> that he didnt know this yet, but that cea can be accompanied by

quite debilitating pain,

> and to just explain that to my insurance company, it shouldn't be

too hard right! Well thats

> what he did I guess, he wrote a quick 1 paragraph letter saying

basically " I am Adam's dermatologist

> and I have treated Adam for the past year for Telengiectasias that

burn. He is trying to get

> coverage for Photoderm to be used to treat this and I am writing on

his behalf "

>

>

> Well surprise, surprise, My insurance company wasnt too impressed.

They rejected the claim.

> They said Telengiectasias are a cosmetic problem, and they wont

pay for a cosmetic procedure.

> Well, You know cea isnt purely cosmetic, and I know rosacea

isnt purely cosmetic, So I

> asked what I had to do next in my effort to get this covered. This

is when I was told I had

> to appeal. Unfortunately, Nobody at Blue Choice knew what the heck

an appeal exactly was.

> One person told me to bring in pictures, letters, articles,

anything I could possibly get

> my hands on to prove that what I wanted done was medically necssary

and submit it all to their

> office. Someone else told me I wasnt ALLOWED to bring ANYTHING, i

had to go downdown and fill

> out a half-page form with my name, address, and quick explanation

as to what I was appealing

> and why! (I feel SO great knowing that these are the people in

charge of my health insurance).

> Well, I decided to compromise. I filled out the half-page

grievance form. I also submitted

> a letter I wrote myself. A copy of which shall appear right

now!

>

>

> " Dear Committee Members:

>

> My name is Adam. I am 19 years old. Dr. xxxxxx xxxxxxxx , M.D., my

dermotologist, submitted

> a request for Photoderm device coverage to alleviate my disabling

rosacea. Dr. xxxxxx's request

> on my behalf was denied based on your determination that this

procedure would be a cosmetic

> one. I believe you have made a mistake.

>

>

> I have a tentative appointment set up to have my first Photoderm

treatment on December 6, 2001

> at Dr. xxxxxx's (different doc, this is the one who im actually

gettin the procedures done

> by) Office based on your decision after reading this letter. I am

not doing this for cosmetic

> reasons - I am doing this for reasons that are medically necessary.

My cea is accompanied

> by severe flushing, swelling, inflammation, and worst of all a

disabling burning pain. My condition

> is worsened by almost everything imaginable. Most foods, sun

exposure, hot weather, warm rooms,

> cold weather, wind, humidity, exercise, embarrassment, anger,

mental concentration, stress,

> facial movements such as chewing and smiling, certain medications,

most topicals, lotions,

> sunscreens, soaps, cleansers, showering, shaving, daily physical

activities (walking up a flight

> of stairs), cuddling up with someone, my head touching my pillow,

and the heat from talking

> on the phone, are just SOME of the things that I run into each and

every day that cause my

> facial pain to get substantially worse.

>

>

>

> I have tried numerous creams, lotions and oral medications in an

effort to alleviate the severe

> discomfort caused by my facial rosacea. The cost before insurance

of all the prescription medications

> I have used in connection with my condition since the beginning of

this calendar year totals

> over $2,500. In recent weeks I have begun experimenting with

different antihistamines in an

> attempt to reduce the swelling, inflammation, and pain associated

with the majority of foods

> I eat. This has not helped much, and I will soon be looking into

adding a -2 inhibitor such

> as Celebrex into my daily regimen.

>

>

> The physical pain I live with every day, which is worsened by

almost any movement I make, has

> become extremely debilitating. This disabling pain has caused me to

become very depressed.

> My condition impairs my ability to function normally in society. I

am unable to work, and have

> come close to dropping out of school more than once. I need to be

able to get rid of the pain

> I live with every day so that I will be able to function normally

once again.

>

>

>

> This condition continues to be extremely costly for all parties

involved. The insurance portion

> alone of the payment for the Psychiatrist I have begun seeing as a

result of the depression

> this pain causes me, is $160 every month. Additional costs include

doctor and dermatologist

> visits that I have needed as a result of my condition. In addition,

I have already gone through

> one month of outpatient hospitalization at a substantial cost,

because of the depression my

> cea has caused me. By eliminating the need for most of these,

five to ten treatments with

> Photoderm (which would cost a total of $1200-$1950) would be

substantially less expensive than

> my current course of therapy has been. Payment for these five to

ten treatments would be an

> extreme hardship for me, as my condition leaves me unable to seek

employment. I have also begun

> to develop early-stage Rhynophymia as a direct result of my

cea, which if left untreated

> may eventually require an even more costly medically necessary

surgery. Photoderm will prevent

> this aspect of my condition from getting worse, eliminating the

possible need for more costly

> surgery in the future. It is important to remember that cea is

a progressive disease. Every

> symptom I have mentioned will more than likely continue to become

more and more debilitating

> in the future without proper treatment.

>

>

>

> My condition and the constant, debilitating pain it causes has left

me unable to work. Since

> developing this condition I have been unable to maintain a steady

job. The pain caused by simply

> placing my face against my pillow at night has left me unable to

sleep properly. I usually

> am finally able to fall asleep around 4 A.M. with the help of

powerful prescription sleep aids

> such as Ambien. Basically, my condition has left me unable to live

a normal life. As you may

> or may not know, Photoderm has many different settings associated

with it. The shallow filters

> are used to remove superficial, cosmetic redness from a person's

skin. These are used for many

> cosmetic procedures. The deeper filters, which the doctor who would

be performing the procedure

> has assured me will be used almost exclusively in my treatment, can

be used to treat the underlying

> vascular reactivity, permanently decreasing my facial swelling,

inflammation, and burning.

> This is why I require treatment with Photoderm.

>

>

>

> I am asking you to please reconsider your decision. I am not having

these treatments done for

> cosmetic reasons. I am having these treatments done because nothing

else has worked. In my

> case, this is anything BUT a cosmetic problem. I have submitted

supporting documentation from

> Dr. xxxxxx (my derm) with my request that you reconsider your

original determination. Thank

> you for your review. "

>

>

> The supporting documentation was actually only one page of the

notes that any dermatologist

> will have about your file in his office that you can request. All

the others were useless,

> as my derm is a dolt. Even the one page that I sent in wasnt all

that useful.

>

>

> Just to clarify, My cea is partially a cosmetic problem. I

hate the red face, and the

> flushing. I hate the swelling even more. The burning exists, and

is quite uncomfortable at

> times, but it is probably #3 or 4 on my list of symptoms in the

order in which I want to alleviate

> them. It is there, and I didn't lie once in the letter, but I did

embelish a little, to try

> and emphasize that this is not a cosmetic problem. I figured, all

I had to do was prove that

> my problem wasnt cosmetic in order to get coverage, so that is what

this letter attempted to

> do. I also threw in a paragraph trying to hint to them that They

as a company would be saving

> money by just lettin' me have this done. Don't know that it was

all that effective. Also,

> I had my claim expedited (hurried along) because I wanted an answer

about coverage before I

> had my second procedure done (I had already had my first treatment

done by this point) I also

> made it sound like I would only be able to have the procedure done

if they paid for it. Again

> I don't know that this helped any.

>

>

> Well three days later I got a phone call. I was rejected again.

The lady on the other end

> seemed REALLY apologetic. I could tell she was probably the one

who had had to make the decision.

> I was sure she had read my letter and probably felt pretty bad. I

sounded like it didn't

> bother me, and I told her " thats ok. But I know I'm right, and

that I should have this approved,

> and I need to know how to proceed from here. "

>

>

> Now that you've gotten this far into this letter, you're probably

saying, Well if all this

> stuff got him rejected, Why is he bothering to tell it to me?!

Well, because it leads up to

> one of the most important parts. This next part is crucial to how

I got coverage. I asked

> the lady " Can you please tell me EXACTLY why my claim was rejected,

in as much detail as possible? "

> and she said " Sure! I'd be happy to! I have everything right in

front of me. Blue Choice

> says that based on all their research, The Only part of cea

that is helped by using a Photoderm

> machine is the telengiectasias. And Telengiectasias are considered

cosmetic " Well This REALLY

> made it alot easier to figure out how to get covered. This right

here is the crux of why Blue

> Choice customers do not usually get coverage for their cea.

Whatever research blue choice

> has says that photoderm is only effective in treating the

telengiectasias. Which is almost

> understandable, because this is what the bulk of cea-related

photoderm articles discuss.

> Articles about Photoderm being used to treat flushing are quite

new! Unfortunately, by this

> point, most people have given up, so they aren't able to proceed.

I asked the lady on the

> phone if I would be able to speak in front of anybody to plead my

case this time. She told

> me I had been able to do that last time if I had wanted, but I gave

that ability up in order

> to have my claim rushed through. Well this time I set a date to

come in in two weeks and present

> my case to a review board. This is a process called medical

review. The Lady told me to be

> prepared to speak for up to 15-20 minutes, and to bring as much

supporting documentation as

> I could find. She said the most helpful by FAR!!! are peer-

reviewed articles.

>

>

> So Now I had to really begin to prepare. I went upstairs and I

brainstormed. What do I need

> to do to get coverage? Well it seems to me I need to show these

people Three things to be

> Guaranteed coverage. I needed to prove my problem was not

cosmetic. To do this, I decided

> I had to prove three things.

>

>

> 1) cea can be accompanied by a debilitated burning sensation

>

> 2) My cea IS accompanied by physical pain

>

> 3) Photoderm IS effective in treating this pain, NOT just at

treating telengiectasias

>

> So I prepared my case, sat down the committee members, and was flat

out honest with them.

> They were all already familiar with my case. I told them my

thought process, and that I figured

> I had to prove my problem wasnt cosmetic, and the three things I

was going to prove to them

> in order to make my case indesputable.

>

>

> The very first thing I did, was explain to them a little about

telengiectasias. Based on all

> the definitions I could find, telengiectasias are actually tiny

little red spider veins on

> your face. Well, I don't really have any of these. I told the

comittee members " I was rejected

> because you believe Photoderm is only effective at treating

Telengiectasias. Well this is

> what telengiectasias are, and here is a picture " I pulled out what

I believe is the last picture

> in Dr Nase's book. " As you can see, I don't have any of these. If

I truly believed Photoderm

> was only going to be effective in treating telengiectasias, its not

hard to imagine that I

> probably would not be spending my time sitting here speaking with

you today " I coudl tell

> they all lookd impressed, including the doctor.

>

>

> Now, Proving that cea can be associated with physical burning

was EASY. I photocopied

> half a dozen pages out of Dr Nase's book. (A book that basically

sumarizes 1100 peer reviewed

> articles) I also explained Dr nase's qualifications (listed in the

beginning of his book)

> and explained that over 1100 peer-reviewed articles were cited in

his book, to give all of

> these photocopies a little more credibility. I also pulled a few

random peer-reviewed articles

> off the internet, and I believe I used a message or two I found in

the archives on this site.

> I also used another cea book I happened to have lying around

the house. I dont think

> any of you will have a problem with this part. especially if you

have Dr nase's book.

>

>

> *Side Note* if Your cea is not accompanied by Absolutely ANY

pain whatsoever, and this

> strategy will not work for you, pick another non-cosmetic side

effect of cea (uncomfortable

> swelling? painful stinging and skin irritation? discomfort to

warm weather? and use the same

> idea.

>

>

> Next, I had to prove that MY cea was accompanied by physical

pain. First I told them a

> little about my personal experiences. I listed some of the many

things in my daily life that

> cause me discomfort. Then I showed them some letters. I mentioned

my letter that I'd already

> written which they all had copies of. I showed them a letter from

My Psychiatrist (who i have

> begun seeing to deal with the depression my cea has caused)

She did not feel comfortable

> at first writing a letter about any physical discomfort, as she

deals with the mental aspect

> only, but I finally was able to convince her to write a pretty good

letter, we wrote it together

> so that she did not need to write anything she felt uncomfortable

saying. Then I got a letter

> from my Primary care doctor explaining that he has treated me for

the physical pain associated

> with cea as well. BY FAR The absolute best letter I got

however came from the Dr's office

> where I was having my procedures done. It was written by the nurse

performing the procedures,

> but signed by the doctor. The nurse is absolutely Amazing, she's a

really smart and knowledgable

> person. Unfortunately I no longer have a copy of this letter I can

put my hands on. What

> is important however, is that it said when I came to her office for

a consultation, I complained

> about a physical pain associated with cea, while in the room

she noticed an active flush

> begin to happen. Even more importantly though, She explained that

she has been treating patients

> for the flushing and burning associated with cea Very

successfully for several years.

> She said that She was very sucessful in reducing the flushing and

burning sensation in almost

> all of her patients. Well, I am SURE this was extremely helpful in

arguing my case.

>

>

> Now for the third part. I had to prove beyond a shadow of a doubt

that Photoderm would be

> useful in treating the Burning sensations associated with cea.

Well, Its pretty hard to

> conduct a scientific study showing the amount of pre-

burningsensations and post-burningsensations

> someone has both b4 and after Photoderm. There is also VERY little

about this written that

> I could find. I thought I was stuck.

>

>

> However, I found MANY places online, some in the archives here, and

two GREAT explanations

> One in Dr nase's book, and another great one in another book I have

called " cea: Your Self-help

> Guide " That Explain VERY Clearly That cea is purely a flushing

disorder. Any and All of

> the other Symptoms of cea (telengiectasias, burning, swelling,

papules, pustules, rhynophymia)

> are ALL caused directly by the flushing. A.K.A. No More Flush =

No More Burn!!! I showed

> all these to the committee, and explained. If the Flush is gone,

the burn is gone, now all

> I have to do, is show you beyond a reasonable doubt that Photoderm

will decrease or eliminate

> my flushing.

>

>

> Well, First things first, I didnt want to make these people feel

stupid. I didn't want to

> make them think i was calling their company a liar either. I

explained it was completely understandable

> that they'd think Photoderm was only effective in treating

Telengiectasias! I mean, Photoderm

> has only been around since what, 1995? Everything about it,

including the research, is all

> brand-new. I explained there were quite a few BRAND NEW peer-

reviewed articles discussing

> the effectiveness of using photoderm to treat facial flushing. It

was QUITE understandable

> that Blue Choice simply hadn't gotten ahold of these articles

yet!

>

>

> Well, Dr Nase's book has several places where it explains Photoderm

is useful in treating cea

> flushing. it also has a spot where it says Photoderm is the BEST

treatment option available

> for treating cea flushing available anywhere. u better believe

I highlighted that when

> i gave them a copy. I also explained that these sections in Dr

nase's book cited 7 or 8 peer-reviewed

> articles. I kept bringing up the phrase peer-reviewed articles in

my presentation AS OFTEN

> AS POSSIBLE. It Instantly doubled my credibility every time I said

it. I cant emphasize that

> enough. I also searched several Photoderm websites that talked

about Photoderm's effectiveness

> in dealing with flushing. usually i would find a paragraph on each

website. I copied each

> of these paragraphs into word, and had one page with 8 different

paragraphs talking about it.

> I wrote in the website I found each of the paragraphs at so the

review board could search

> the sites at their leisure. Whenever possible I also put the

Doctor's name who was associated

> with the site.

>

>

> I ended with what was BY FAR THE MOST IMPORTANT ARTICLE OR ANYTHING

THAT I SUBMITTED TO THE

> REVIEW BOARD. THIS PART IM SURE WAS KEY! I gave them two full-

length articles that discuss

> the effectiveness of treating cea Flushing with Photoderm. One

of Which was written by

> Dr. Bitter himself. This was the most important thing I gave them

I believe. The second most

> important was probably the letter written by the nurse performing

the procedures. The third

> was probably the letter I had written myself. I found BOTH of

these articles on the internet.

> Unfortunately I do NOT have the websites anymore. You could

probably find them if you looked

> enough. However, I DID post to a few people some of the websites I

used to find information

> about Photoderm treating facial flushing for my presentation. If

anyone here has any of those

> websites listed anywhere, Please post them to the group. In case

those people didn't read

> this far into the letter, If anyone is curious about this part, I'd

urge you to post a quick

> message to the group asking if anyone has a few of the websites I

suggested they look at for

> this matter.

>

>

> During the presentation I took everything step by step. I

explained each article, each photocopy,

> each everything, and then passed it around. I let them keep

everything. I explained This

> had impacted my life. I leave the house probably 3 days a week

now. I have just started school

> up again this year, after almost dropping out of high school. I

explained that cea has

> completely changed my life. I am slowly regaining control over my

life even though my cea

> is not gone, however it is still a struggle. I did NOT embelish

that much at this stage, I

> just laid down the facts for them, clearly and consisely.

>

>

> They contacted me three days later saying I had recieved full

coverage.

>

>

> Sorry again that this letter may seem rushed and disorganized.

Even writing this as fast as

> I could, it STILL took me almost two hours, so, Hopefully it wont

take you too long to read!!!!

>

>

>

> I REALLY Hope this helps somebody out there!!!!!! Please let me

know if you have any more

> questions/feedback! "

>

>

> Adam

> Filter@R...

>

>

>

>