Insurance Denial

[Guest guest]

Hi Kim,

Do you have a copy of the 60 referrals regarding chronic lyme. I don't

have it on my computer, but will send a paper copy to you.

Referrals to articles will scare the insurance co. If you can, also get

a lawyer, get on TV, newspaper, anything, ..........if they are going to

give you a hard time.

Hugs,

Connie, MI

[Guest guest]

You may want to try the free med program. Hope the info. below can help.

best,

lea

www.themedicineprogram.com

or

http://www.phrma.org/patients/

1.Free medications

http://www.themedicineprogram.com/

The Medicine Program RX

P.O. Box 515

Doniphan, MO 63935-0515

Telephone (573) 9967300

2. Many pharmaceutical companies have patient assistance programs and

provide free meds to those who need them. For IV Rocephin, Roche

Pharmaceuticals manufacturers it, and their phone number is (973) 235-5000.

Call and ask about their patient assistance program.

For a list of other drugs, their manufacturer, and contact information,

check out:

http://www.institutedc.org/pd370r4.htm

3. The following website is for free or low cost medical care and drugs. The

organization was established by volunteers dedicated to helping people who

cannot afford medical care or prescription medicine.

www.FinancialAssistanceNetwork.org

or the phone number is 202 595-1039

4. Drug assistance program:

http://www.phrma.org/patients/

5. This site lists a lot of the different meds and how to go about getting

them. http://NEEDYMEDS.COM/

6. Free Medications for Low Income Patients

http://www.cpmission.com/gallery.html

7. Links to Insurance Assistance, Claims, Disabilities, etc.:

http://www.geocities.com/HotSprings/Oasis/6455/insurance-links.html

8. The following are state telephone numbers to call for information about

pharmaceutical-assistance programs in that state. Sorry not all states are

listed. This came from an AARP newsletter.

Connecticut:860-832-9265

Delaware: 800-996-9969, ext.17

Maine: 888-600-2466

land: 410-767-5394

Massachusetts: 800-243-4636

Michigan: 517-373-8230

Minnesota: 800-333-2433

Neveda:800-243-3638

New Jersey: 800-792-9745

New York:800-332-3742

Pennsylvania:800-225-7223

Rhode Island:401-222-2858

Vermont:800-529-4060

Wyoming: 307-777-7531

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>From: meme schmo <meme21998@...>

>Reply-

>

>Subject: [ ] Insurance Denial

>Date: Sat, 1 Jun 2002 18:23:25 -0700 (PDT)

>

>Hi,

>I have been reading this group for a while. I have

>Chronic Neuro Lyme that went undiagnosed for 10 years.

>I now have a LLMD who is treating me very aggressively

>with IV Claforan. My insurance will not cover any of

>this because I was on IV 3 years ago for 4 weeks. They

>are claiming this treatment is not medically

>necessary.

>

>Does anyone know what I can do to fight this? I have

>appealed to my ins. company and haven't gotten a

>response. Meanwhile, I started the IV 8 weeks ago. I

>am paying for everything out of pocket and just got a

>4,000 bill from having the catheter inserted.

>

>Any input would be appreciated.

>

>Thanks,

>Kim Connelly

>

>__________________________________________________

>

[Guest guest]

I sent my health carrier over 100 references to

different articles regarding chronic lyme and the use of

long-term antibiotics. They said it was anecdotal,

involved animal studies, and only listed the summaries

instead of the full studies. And they immediately

denied it.

Basically, they said too bad, we'll just continue to say

no because you can't sue us.

But that's United Healthcare. Perhaps your carrier will

have a different answer.

> Hi Kim,

> Do you have a copy of the 60 referrals regarding chronic lyme. I don't

> have it on my computer, but will send a paper copy to you.

> Referrals to articles will scare the insurance co. If you can, also get

> a lawyer, get on TV, newspaper, anything, ..........if they are going to

> give you a hard time.

>

> Hugs,

> Connie, MI

>

>

>

[Guest guest]

> But that's United Healthcare. Perhaps your carrier will

> have a different answer.

I am amazed at how many people cannot get coverage with UHC. I have them,

hubbys Railroad, and they pay 100% for me and have never given me problems.

Now every year I have to get my LLMD considered in network, but since I live

rurally and there are few Drs around me, my LLMD would pass that ' no Dr

within such and such area just fine. I do know that with hubbys job , they

own part of the ins so maybe that makes a difference?

Have you asked for a case manager? It seems like they can make a huge

difference and its easy to do. Good luck!

[Guest guest]

Hi :

Is this an HMO plan?

thank you

best,

lea

>From: " Rodney & " <rod@...>

>Reply-

>< >

>Subject: Re: [ ] Insurance Denial

>Date: Mon, 3 Jun 2002 11:02:46 -0500

>

>

> > But that's United Healthcare. Perhaps your carrier will

> > have a different answer.

>

>

>

>I am amazed at how many people cannot get coverage with UHC. I have them,

>hubbys Railroad, and they pay 100% for me and have never given me problems.

>Now every year I have to get my LLMD considered in network, but since I

>live

>rurally and there are few Drs around me, my LLMD would pass that ' no Dr

>within such and such area just fine. I do know that with hubbys job , they

>own part of the ins so maybe that makes a difference?

> Have you asked for a case manager? It seems like they can make a

>huge

>difference and its easy to do. Good luck!

>

>

_________________________________________________________________

Send and receive Hotmail on your mobile device: http://mobile.msn.com

[Guest guest]

On Thu, 17 Jun 2004 22:27:50 -0000, you wrote:

>anthem insurance (PPO) denying lab test costs because hypogonadism

>is characterized as sexual dysfunction which is not covered under

>the policy, even though sexual dysfunction is a small part of what

>this condition entails.

>

>Prescription drugs would likewise not be covered.

>

>Of course menopause is fully covered.

>

>This makes no sense to me.

>

>Would appreciate anyone's experience with this, and/or other

>diagnosis codes that are related that might not be denied.

>

>LM

What are your T levels?

[Guest guest]

> anthem insurance (PPO) denying lab test costs because hypogonadism

> is characterized as sexual dysfunction which is not covered under

> the policy, even though sexual dysfunction is a small part of what

> this condition entails.

>

> Prescription drugs would likewise not be covered.

>

> Of course menopause is fully covered.

>

> This makes no sense to me.

>

> Would appreciate anyone's experience with this, and/or other

> diagnosis codes that are related that might not be denied.

>

> LM

Osteoporosis or osteopenia caused by hypogonadism might be a covered

condition.

Brad

[Guest guest]

My doc uses diagnosois code 257.8 " Other testicular

dysfunction "

> anthem insurance (PPO) denying lab test costs because

hypogonadism

> is characterized as sexual dysfunction which is not covered

under

> the policy, even though sexual dysfunction is a small part of

what

> this condition entails.

>

> Prescription drugs would likewise not be covered.

>

> Of course menopause is fully covered.

>

> This makes no sense to me.

>

> Would appreciate anyone's experience with this, and/or other

> diagnosis codes that are related that might not be denied.

>

> LM

[Guest guest]

Just an idea, but maybe if you can get your pituitary hormones tested

as well you might have some more evidence to fight them.

Mark

[Guest guest]

Hi Deborah,

Glad to see you made it to the forum with no problem. It's great to

have you here.

sometimes the individual emails can be overwhelming so you might

want to change your email settings or we can do it too. You can get

daily digest, individual, no email (you can go directly to the

website and read and post) or you can be put on email notifications

for special notices only.

since I've already emailed you some links about insurance appeals,

I'll leave it here for some who have actually had to deal with the

process to give you their experiences.

People here are always most happy to help out so anything you care

to ask.. ask away.

Hope all gets settled with the insurance company.. I'm sure things

will work out for you.. Just be persistant and don't take no for an

answer.

Hugs,

Silly MI

In , " deborahjstroud " <deborahjstroud@e...>

wrote:

>

>

> Hello everyone. I am Deborah from North Carolina and this is my

> first time posting to the website. I have just been told about

> and I am already enjoying reading the emails from so many.

[Guest guest]

Deborah,

Welcome to CI Hear. I wish you were joining with a more positive reason but

I am sure that you will be hearing from others who have been in a similar

situation. One thing that I noticed was you had an approval in December.

Was this a verbal approval or was it in writing? Sometimes the insurance

companies make errors so if you received a written notice in December, that

should stick and you should let them know that this has already been

approved. You would just need to contact them and refer them back to the

approval.

Did the notices you received state why you were denied? They have to give

you a reason and in all probability this is a fluke. Your implant center

may be able to straighten this out in a matter of a few days.

I would not give up on that February 15th date until you absolutely have to.

We are here 24/7 and we’re rooting for you all the way.

Alice

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[Guest guest]

Hi Shellie

How frustrating that your insurance company has denied paying for the T & A. We

have the same problem. Mainly because Emma (27 months) has never had even a sore

throat, let alone tonsillitis. They don't recognise as a reason to have

T & A. We are lucky to be living in South Africa, where our private medical care

is excellent but not nearly as expensive as in the US so we are able to pay for

it ourselves.

If I were you I wouldn't give up yet pushing the insurance company. Get

documentation backing up your reason for T & A (there are some on the file section

of this board), letters from you ENT recommending the procedure etc. In my

experience insurance company are quick with turning down but you can often

convince them otherwise if you don't give up.

Take care

Inga

[Guest guest]

Shellie, get your doctor who'll do the T & A procedure to call (or write

a letter to) your insurance company justifying the procedure. In the

mean time, try typing [ " insurance claim denials " + tips] (minus the

brackets) into your favorite search engine for help online.

A lot of insurance companies deny claims (especially large ones) on the

hopes that their clients will give up. Don't give up.

[Guest guest]

--

HI my name is Suzanne and I'm new to this group. I was wondering what is T & A?

My son

who is 6 years old has and I'm not sure what you all writing about?

Please help

Thank you!

[Guest guest]

Hi Suzanne,? I am also new to the group, but my daughter had tubes put in her

ears.? The ENT, ears nose throat doctor performed the surgery.? This same doctor

removes tonsells and adnoids, T & A, I know sounds lewd at first.?

[Guest guest]

Shari,

Please call UnitedHealthcare and ask to speak with a supervisor...... or have

someone call for you.

Obviously, whoever worked on your case didn't know what they were doing.

UnitedHealthCare paid for both of my cochlear implants.... the first in 2001 and

the second in 2006. All I paid was a $25 copay for the hospital.

Happy Hearing!

Carol

Boca Raton, FL

N24C 3G left ear -12/11/01-upgraded to Freedom on 2/19/08

N Freedom- right ear- implanted 3/01/06 activated 4/6/06

Insurance Denial

I joined the list about a month ago when I found out I was a candidate for a CI.

I have almost no hearing in the worse ear on the left side. With the aid of the

right ear, I have 35% speech comprehension.

I received a denial letter from my husband's group health plan,

UnitedHealthcare. I contacted the provider and though the letter states a copy

was sent to the ENT, they didn't get it. I sent them a copy. I also initiated an

appeal with the Let Them Hear Foundation.

The reason for the denial was that the CI was " not proven to be safe and

effective " . How long ago was that?

I, too, am legally blind from Usher syndrome. While I can still read regular

print, I have almost no peripheral vision. I do have good central vision at this

point.

Thank you,

Shari from WI

---------------------------------

Never miss a thing. Make your homepage.

[Guest guest]

Shari,

Sorry to hear of the initial denial. Hang in there and do what Carol

suggested.Good luck and keep us posted.

[Guest guest]

>

> Shari,

> Sorry to hear of the initial denial. Hang in there and do what

Carol

> suggested.Good luck and keep us posted.

>

>

We have United health Care as a secondary, as we are on Medicare now.

I'm scheduled for a CI on April 14th.

A few days ago I got a letter from the Doctor's office about

coverage.

They said:

" On 3/6/08 I spoke with a S. at your Ins. Co.

He said no precert.(precertification?)was needed for your Ins.

Then he checked the CPT code and no Predetermination of medical

necessity was needed, but they may request further documentation

after billing is done. "

I'm assuming this was United Health as I thought coverage by

Medicare was a given.

If I was you, I'd pursue this as suggested. Good luck!

[Guest guest]

IMPORTANT! Make sure you get a predetermination IN WRITING! With my first

implant, we insisted that we get a letter and they did send it to me.

After the surgery, when they got the bill, UHC denied it. When we said they

approved it in writing, they say " oh " " yes I see that in your file " . So they

had to pay for it.

Fortunately, we insisted that we get a predetermination and made sure we had it

in writing prior to the surgery.

Sooooooo...... don't fall for their trickery. Get it in writing. It's a hard

lesson to learn if you don't.

Happy Hearing!

Carol

Boca Raton, FL

N24C 3G left ear -12/11/01-upgraded to Freedom on 2/19/08

N Freedom- right ear- implanted 3/01/06 activated 4/6/06

Re: Insurance Denial

>

> Shari,

> Sorry to hear of the initial denial. Hang in there and do what

Carol

> suggested.Good luck and keep us posted.

>

>

We have United health Care as a secondary, as we are on Medicare now.

I'm scheduled for a CI on April 14th.

A few days ago I got a letter from the Doctor's office about

coverage.

They said:

" On 3/6/08 I spoke with a S. at your Ins. Co.

He said no precert.(precertification?)was needed for your Ins.

Then he checked the CPT code and no Predetermination of medical

necessity was needed, but they may request further documentation

after billing is done. "

I'm assuming this was United Health as I thought coverage by

Medicare was a given.

If I was you, I'd pursue this as suggested. Good luck!

[Guest guest]

Shari,

The safe part is a questionable call. There are risks with any surgical

procedure, even wart removal from the hands. The issue is whether there is

something in your medical records which indicates that CI surgery would be

unusually risky. If so, your doctor should have already advised you of such.

As for the effectiveness of cochlear implants - there are simply too much

variance in the results for surgeons to make predictions about the results.

This is not because so many variables that are difficult to measure come into

play.

I just read my doctors letter to my insurance carrier (Physicians Plus) for my

other ear. It was conservative to the extreme and even noted to the insurance

company that if the CI does not work the processor can be returned to the

manufacturer.

You also may wish to check with your husband's employee relations office to

discuss the health care insurance options to see if you can switch plans during

next open season. At UW Madison hospital surgery and the processor cost

approximately $52,000. Physicians Plus paid all but $2200. The supplemental

insurance I have covered all but $250 of what PP would not pay.

The down side of PP is a a $250,000 lifetime surgery coverage. If I get a

second CI I will probably need to change my health insurance provider next open

season as I will have used up $100,000 plus.

R

Shari <skedi1@...> wrote:

I joined the list about a month ago when I found out I was a candidate for a

CI. I have almost no hearing in the worse ear on the left side. With the aid of

the right ear, I have 35% speech comprehension.

I received a denial letter from my husband's group health plan,

UnitedHealthcare. I contacted the provider and though the letter states a copy

was sent to the ENT, they didn't get it. I sent them a copy. I also initiated an

appeal with the Let Them Hear Foundation.

The reason for the denial was that the CI was " not proven to be safe and

effective " . How long ago was that?

I, too, am legally blind from Usher syndrome. While I can still read regular

print, I have almost no peripheral vision. I do have good central vision at this

point.

Thank you,

Shari from WI

---------------------------------

Never miss a thing. Make your homepage.

[Guest guest]

I have to second Carol's recommendation. Prior to surgery I was told

that all the expenses connected to my cochlear implant were covered by

my insurer(s). After the surgery, I was informed that while the surgery,

and the processor were covered the pre-testing and post surgical mapping

that are essential are not covered?

I wish I had a pre-determination in writing? Trickery? A hard lesson

indeed!

Tom

Staten Island New York

Implanted 2/8/2008 Freedom

Activated 3/27/2008

Carol wrote:

>

> IMPORTANT! Make sure you get a predetermination IN WRITING! With my

> first implant, we insisted that we get a letter and they did send it

> to me.

> After the surgery, when they got the bill, UHC denied it. When we said

> they approved it in writing, they say " oh " " yes I see that in your

> file " . So they had to pay for it.

> Fortunately, we insisted that we get a predetermination and made sure

> we had it in writing prior to the surgery.

> Sooooooo...... don't fall for their trickery. Get it in writing. It's

> a hard lesson to learn if you don't.

> Happy Hearing!

> Carol

> Boca Raton, FL

> N24C 3G left ear -12/11/01-upgraded to Freedom on 2/19/08

> N Freedom- right ear- implanted 3/01/06 activated 4/6/06

>

> Re: Insurance Denial

>

>

> >

> > Shari,

> > Sorry to hear of the initial denial. Hang in there and do what

> Carol

> > suggested.Good luck and keep us posted.

> >

> >

>

> We have United health Care as a secondary, as we are on Medicare now.

> I'm scheduled for a CI on April 14th.

> A few days ago I got a letter from the Doctor's office about

> coverage.

> They said:

> " On 3/6/08 I spoke with a S. at your Ins. Co.

> He said no precert.(precertification?)was needed for your Ins.

> Then he checked the CPT code and no Predetermination of medical

> necessity was needed, but they may request further documentation

> after billing is done. "

> I'm assuming this was United Health as I thought coverage by

> Medicare was a given.

> If I was you, I'd pursue this as suggested. Good luck!

>

>

[Guest guest]

If she gets her insurance through her husband's job, they might only have the

choice of the level of coverage, not plans. They need to make sure they choose

the highest level available, which will cost more in premiums but also minimize

out of pocket expenses.

Also, Shari, do you have a flex spending account available for medical expenses

via your husband's job? I'd be electing to enroll in that and putting in every

penny I could afford up to the max. It saved me a lot of hassles with having to

come up with the out of pocket and copays when I got my implant last year.

Kat

From: R C

Sent: Wednesday, March 19, 2008 3:05 PM

Subject: Re: Insurance Denial

Shari,

The safe part is a questionable call. There are risks with any surgical

procedure, even wart removal from the hands. The issue is whether there is

something in your medical records which indicates that CI surgery would be

unusually risky. If so, your doctor should have already advised you of such.

As for the effectiveness of cochlear implants - there are simply too much

variance in the results for surgeons to make predictions about the results. This

is not because so many variables that are difficult to measure come into play.

I just read my doctors letter to my insurance carrier (Physicians Plus) for my

other ear. It was conservative to the extreme and even noted to the insurance

company that if the CI does not work the processor can be returned to the

manufacturer.

You also may wish to check with your husband's employee relations office to

discuss the health care insurance options to see if you can switch plans during

next open season. At UW Madison hospital surgery and the processor cost

approximately $52,000. Physicians Plus paid all but $2200. The supplemental

insurance I have covered all but $250 of what PP would not pay.

The down side of PP is a a $250,000 lifetime surgery coverage. If I get a second

CI I will probably need to change my health insurance provider next open season

as I will have used up $100,000 plus.

R

Shari <skedi1@...> wrote:

I joined the list about a month ago when I found out I was a candidate for a CI.

I have almost no hearing in the worse ear on the left side. With the aid of the

right ear, I have 35% speech comprehension.

I received a denial letter from my husband's group health plan,

UnitedHealthcare. I contacted the provider and though the letter states a copy

was sent to the ENT, they didn't get it. I sent them a copy. I also initiated an

appeal with the Let Them Hear Foundation.

The reason for the denial was that the CI was " not proven to be safe and

effective " . How long ago was that?

I, too, am legally blind from Usher syndrome. While I can still read regular

print, I have almost no peripheral vision. I do have good central vision at this

point.

Thank you,

Shari from WI

---------------------------------

Never miss a thing. Make your homepage.

[Guest guest]

Not sure if anyone can help. My daughter has moderate-severe deformational

plagiocephaly. Our insurance company denied our claim because they said they

are only covered for adjunctive use for infants from 3-18mts of age whose

synostosis has been surgically corrected, but who still have moderate to severe

cranial deformities.

Not really sure where to go from here. I'd be grateful for any help. thanks

Lucy's Mom

[Guest guest]

If usafgirl means you're Air Force and your insurance is Tricare it's the same as our case. We paid out of pocket but you may want to try asking the Air Force Aid Society for help. I just did a search and found that mentioned in past messages.

, Tampa, FL, 29 mos, Starband grad Mar 2010

Plagiocephaly From: jennifermonica@...Date: Sat, 26 Jun 2010 18:52:57 +0000Subject: Insurance Denial

Not sure if anyone can help. My daughter has moderate-severe deformational plagiocephaly. Our insurance company denied our claim because they said they are only covered for adjunctive use for infants from 3-18mts of age whose synostosis has been surgically corrected, but who still have moderate to severe cranial deformities. Not really sure where to go from here. I'd be grateful for any help. thanksLucy's Mom

[Guest guest]

Hi,

I'm sorry to hear about your insurance's denial. I'm not sure that I understand

your situation, but I know that insurance companies are notorious for denying

claims even when you meet their guidelines. My company denied us even though we

matched all the criteria and didn't send us their decision letter until 5 days

before the deadline for the appeal. Ridiculous. Of course they said they sent

it earlier, which they did not. We were supposed to get 60 days notice. Wow.

Anyway, if you think you fall under their guidelines despite the denial, I would

appeal immediately. I would also double check that they aren't lying and

telling you that is the only situation that is covered.

If you really don't match their criteria, then I'm sorry I wish I knew more to

help you. There's always the possibility of making a deal for a payment plan

with your treatment provider and/or asking the church for donations. Sell what

you can on ebay, have some yard sales, get some part-time work temporarily if

your situation permits.

I think there are others on here that even went so far as to go to some state

authority to appeal, but I don't know what that would be.

Praying for you that someone will have some more advice to fit your situation.

Take care,

~ Liam's Mom

>

> Not sure if anyone can help. My daughter has moderate-severe deformational

plagiocephaly. Our insurance company denied our claim because they said they

are only covered for adjunctive use for infants from 3-18mts of age whose

synostosis has been surgically corrected, but who still have moderate to severe

cranial deformities.

>

> Not really sure where to go from here. I'd be grateful for any help. thanks

>

> Lucy's Mom

>