Photoderm + Insurance (LONG, SKIP IF NOT INTERESTED IN HOW TO GET PHOTODERM COVERED BY INSURANCE)

January 21, 2002

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@...

January 22, 2002

Adam,

Great job, glad you got coverage. Hopefully, more people will do this

so that the insurance companies will cover more. I wish I had the time as I

will need to go back for more photoderm treatments. I have had 10 I think

now (with a Bitter Sr. trained phy), but I really havent seen that much

improvement. The last one was about a year ago.

I think there are ways to treat now, using different machines and

settings to treat deeper vessels (like mine) so Im hoping that will work for

me. It sounded like your physician didnt seem to know a whole lot about

rosacea, maybe I am wrong. I would hate for you to work that hard and in

the end not get good results because of the docs lack of ability. I think I

suffered from incorrect setting not targeting the right area of my rosacea

(deeper vessels) and it was for the most part a waste. I am not willing to

give up on photoderm yet, but rather make sure I do it right next time.

January 22, 2002