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

[Guest guest]

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

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