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

[Guest guest]

All the hoops insurance companies make patients and doctors jump

through...but it sounds like you jumped through them with grace.

Congratulations.

I'm curious why you had your dermatologist, and not the doctor who

would perform your photoderm, file the initial letter to your

insurance company?

Marjorie

Marjorie Lazoff, MD

[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...

>

>

>

>