Re: Appeal Letter to insurance company that denied me coverage..looking for feedback

[Guest guest]

I recently was denied for the gel. I seek info in how I could overturn my

insurance company paying for it, but I didn't want to even if my doc would have

fought to do so. Instead I have went back to shots. Its interesting your

insurance doesn't cover the cheaper form of T.

Maybe they cover another form of T rather than that one specifically.

Find out what you can do to appeal properly and then bring it to your Endo

doctor. You have have to prove why they need to cover this med, then do so. If

it inconveniences you to prove why, try another form of T. If you can prove why

they need to pay for this specific form of T, prove your case. If not, try

another form of T.

From: Woolf <fkw1122@...>

Subject: Appeal Letter to insurance company that denied me

coverage..looking for feedback

Date: Saturday, April 18, 2009, 9:12 PM

Highmark Security Blue

Appeals Department

P.O. Box 535047

Pittsburgh, PA 15253-5047

To Whom It May Concern:

I was recently denied coverage for a prescription. The medication is

Testosterone Enanthante. I have been taking this medication for over two years.

I was initially turned down because you didn't have my current blood work. My

Endocrinologist, Doctor Jill Felder, forwarded you the information, and I was

turned down again. If your reason for turning me down was based on my current

blood work, then you made an error. I'll always test in the upper normal range

as I am currently taking Testosterone. The reason I need to go through this

process is I switched to Security Blue this year after being with UPMC for Life

the previous few years. They approved me being on Testosterone and renewed the

approval each year.

Having been on exogenous testosterone, my testicles have shut down from making

any, and have also atrophied somewhat. This is a normal side effect of being on

testosterone, and I expect I will be on it for the rest of my life. If you

continue to deny my claim, my body will run out within a week or two after my

last injection. If this happens I would likely experience the following:

* Osteoporosis

* Diabetes

* Mental fog or a lack of concentration

* A lack of ambition

* Inability to focus

* Loss of muscle mass and fat redistribution

* Weight gain

In 2003, I was diagnosed with diabetes. It took a combination of losing weight,

Actos, and Testosterone all working together to keep my blood sugar under

control. Testosterone helps regulate blood sugar.

In 2005, I was diagnosed with osteopenia in my spinal column. Again

testosterone helps maintain strong bones. I also take calcium and Boniva. It

was due to low testosterone (hypogonadism) that led to me becoming permanently

disabled in 2000. I need to be on testosterone to maintain my bones and

strengthen the weakened bones in my spinal column.

When I went on testosterone, I regained a mental decisiveness and clarity that I

hadn't realized I had lost over the years. This enabled me to take control of

my life and not just go through the motions. If my body went into a

testosterone crash, I'd lose my mental sharpness, possibly falling into a severe

depression. I'm already physically disabled; I need my mental clarity to have a

reasonable quality of life.

Sincerely,

K. Woolf

[Guest guest]

Hi ,  I had a very similar situation with Highmark ( we must live in the

same region)  When I  initially began TRT it was thru self injections of

Delatestryl.    My doc the insurance would not pay for me to have this done

every 10 days thus I was trained on how to self administer the shots.    That

worked for about a year and  half until I had developed cellulitis from a bad

injection.   That caused me to spend a week in the hospital with IVs and nearly

losing my leg from the infection.   My doc then put me Androderm ( TRT

patch) but that caused burns and welts.   The only option left was Androgel.  

We had to fight like hell with Highmark since it is the most expernsive of the

TRTs out there.    The weasly, cheap bastards still denied me for it although

the doc had given medical necseeity documentation.   Finally after about 2

months and threats of my lawyer they covered it.  In my experience, insurance

companies want

nothing to do hypogonadsim or medication to treat it.    Hang in there

.          

From: Woolf <fkw1122@...>

Subject: Appeal Letter to insurance company that denied me

coverage..looking for feedback

Date: Saturday, April 18, 2009, 9:12 PM

Highmark Security Blue

Appeals Department

P.O. Box 535047

Pittsburgh, PA 15253-5047

To Whom It May Concern:

I was recently denied coverage for a prescription. The medication is

Testosterone Enanthante. I have been taking this medication for over two years.

I was initially turned down because you didn't have my current blood work. My

Endocrinologist, Doctor Jill Felder, forwarded you the information, and I was

turned down again. If your reason for turning me down was based on my current

blood work, then you made an error. I'll always test in the upper normal range

as I am currently taking Testosterone. The reason I need to go through this

process is I switched to Security Blue this year after being with UPMC for Life

the previous few years. They approved me being on Testosterone and renewed the

approval each year.

Having been on exogenous testosterone, my testicles have shut down from making

any, and have also atrophied somewhat. This is a normal side effect of being on

testosterone, and I expect I will be on it for the rest of my life. If you

continue to deny my claim, my body will run out within a week or two after my

last injection. If this happens I would likely experience the following:

* Osteoporosis

* Diabetes

* Mental fog or a lack of concentration

* A lack of ambition

* Inability to focus

* Loss of muscle mass and fat redistribution

* Weight gain

In 2003, I was diagnosed with diabetes. It took a combination of losing weight,

Actos, and Testosterone all working together to keep my blood sugar under

control. Testosterone helps regulate blood sugar.

In 2005, I was diagnosed with osteopenia in my spinal column. Again testosterone

helps maintain strong bones. I also take calcium and Boniva. It was due to low

testosterone (hypogonadism) that led to me becoming permanently disabled in

2000. I need to be on testosterone to maintain my bones and strengthen the

weakened bones in my spinal column.

When I went on testosterone, I regained a mental decisiveness and clarity that I

hadn't realized I had lost over the years. This enabled me to take control of my

life and not just go through the motions. If my body went into a testosterone

crash, I'd lose my mental sharpness, possibly falling into a severe depression.

I'm already physically disabled; I need my mental clarity to have a reasonable

quality of life.

Sincerely,

K. Woolf

[Guest guest]

My insurance did this to me last yr. I am retired from Chry. they were the ones

that told CareMark not to pay of my Testosterone shots.

It took me 5 letters of appeal to get them to pay I am in the Union and my Union

Rep was working on it getting not were.

I then got a letter saying my labs don't show my T levels low. WTF my labs

show my levels on T after being on TRT over 25 yrs for them to do this nuts.

I have copy's of all my labs and found the one that was done by an Endo that

took me off TRT for 4 weeks this lab show me way to low we sent them a FAX and

then they started paying for it.

Still this is to me just more harassment for use sick people. I was having to

pay for this out of my own money for 4 months and they never gave me the money

back. I feel this is just the beginning of this after this happened I was

turned down for more meds and my Dr. had to send them letters.

Co-Moderator

Phil

> From: Woolf <fkw1122@...>

> Subject: Appeal Letter to insurance company that denied me

coverage..looking for feedback

>

> Date: Saturday, April 18, 2009, 5:12 PM

> Highmark Security Blue

> Appeals Department

> P.O. Box 535047

> Pittsburgh, PA 15253-5047

>

> To Whom It May Concern:

> I was recently denied coverage for a prescription. The

> medication is Testosterone Enanthante. I have been taking

> this medication for over two years. I was initially turned

> down because you didn't have my current blood work. My

> Endocrinologist, Doctor Jill Felder, forwarded you the

> information, and I was turned down again. If your reason

> for turning me down was based on my current blood work, then

> you made an error. I'll always test in the upper normal

> range as I am currently taking Testosterone. The reason I

> need to go through this process is I switched to Security

> Blue this year after being with UPMC for Life the previous

> few years. They approved me being on Testosterone and

> renewed the approval each year.

>

> Having been on exogenous testosterone, my testicles have

> shut down from making any, and have also atrophied somewhat.

> This is a normal side effect of being on testosterone, and

> I expect I will be on it for the rest of my life. If you

> continue to deny my claim, my body will run out within a

> week or two after my last injection. If this happens I

> would likely experience the following:

> * Osteoporosis

> * Diabetes

> * Mental fog or a lack of concentration

> * A lack of ambition

> * Inability to focus

> * Loss of muscle mass and fat redistribution

> * Weight gain

>

> In 2003, I was diagnosed with diabetes. It took a

> combination of losing weight, Actos, and Testosterone all

> working together to keep my blood sugar under control.

> Testosterone helps regulate blood sugar.

>

> In 2005, I was diagnosed with osteopenia in my spinal

> column. Again testosterone helps maintain strong bones. I

> also take calcium and Boniva. It was due to low

> testosterone (hypogonadism) that led to me becoming

> permanently disabled in 2000. I need to be on testosterone

> to maintain my bones and strengthen the weakened bones in my

> spinal column.

>

> When I went on testosterone, I regained a mental

> decisiveness and clarity that I hadn't realized I had

> lost over the years. This enabled me to take control of my

> life and not just go through the motions. If my body went

> into a testosterone crash, I'd lose my mental sharpness,

> possibly falling into a severe depression. I'm already

> physically disabled; I need my mental clarity to have a

> reasonable quality of life.

>

>

> Sincerely,

>

> K. Woolf

>

>

>

>

> ------------------------------------

>

>

[Guest guest]

>

Hi ,

Could be. I'm in Pittsburgh. I didn't have any problems with UPMC For

Life..the reason I switched this year was that UPMC isn't covering generic

medications through the Medicare Part D donut starting this year. I get

additional financial assistance from Social Security and the donut doesn't

affect me, but I didn't want to take any chances.

[Guest guest]

If you haven't sent it yet it's also worth mentioning that low T leads

to low bone density and osteoporosis

On Sat, 18 Apr 2009 21:12:48 -0000, you wrote:

>Highmark Security Blue

>Appeals Department

>P.O. Box 535047

>Pittsburgh, PA 15253-5047

>

>To Whom It May Concern:

>I was recently denied coverage for a prescription. The medication is

Testosterone Enanthante. I have been taking this medication for over two years.

I was initially turned down because you didn't have my current blood work. My

Endocrinologist, Doctor Jill Felder, forwarded you the information, and I was

turned down again. If your reason for turning me down was based on my current

blood work, then you made an error. I'll always test in the upper normal range

as I am currently taking Testosterone. The reason I need to go through this

process is I switched to Security Blue this year after being with UPMC for Life

the previous few years. They approved me being on Testosterone and renewed the

approval each year.

>

>Having been on exogenous testosterone, my testicles have shut down from making

any, and have also atrophied somewhat. This is a normal side effect of being on

testosterone, and I expect I will be on it for the rest of my life. If you

continue to deny my claim, my body will run out within a week or two after my

last injection. If this happens I would likely experience the following:

> * Osteoporosis

> * Diabetes

> * Mental fog or a lack of concentration

> * A lack of ambition

> * Inability to focus

> * Loss of muscle mass and fat redistribution

> * Weight gain

>

>In 2003, I was diagnosed with diabetes. It took a combination of losing

weight, Actos, and Testosterone all working together to keep my blood sugar

under control. Testosterone helps regulate blood sugar.

>

>In 2005, I was diagnosed with osteopenia in my spinal column. Again

testosterone helps maintain strong bones. I also take calcium and Boniva. It

was due to low testosterone (hypogonadism) that led to me becoming permanently

disabled in 2000. I need to be on testosterone to maintain my bones and

strengthen the weakened bones in my spinal column.

>

>When I went on testosterone, I regained a mental decisiveness and clarity that

I hadn't realized I had lost over the years. This enabled me to take control of

my life and not just go through the motions. If my body went into a

testosterone crash, I'd lose my mental sharpness, possibly falling into a severe

depression. I'm already physically disabled; I need my mental clarity to have a

reasonable quality of life.

>

>

>Sincerely,

>

> K. Woolf

>

[Guest guest]

On Sun, 19 Apr 2009 05:07:20 -0700 (PDT), you wrote:

>

>Hi ,  I had a very similar situation with Highmark ( we must live in the

same region)  When I  initially began TRT it was thru self injections of

Delatestryl.    My doc the insurance would not pay for me to have this done

every 10 days thus I was trained on how to self administer the shots.    That

worked for about a year and  half until I had developed cellulitis from a bad

injection.   That caused me to spend a week in the hospital with IVs and nearly

losing my leg from the infection.   My doc then put me Androderm ( TRT

patch) but that caused burns and welts.   The only option left was Androgel.  

We had to fight like hell with Highmark since it is the most expernsive of the

TRTs out there.    The weasly, cheap bastards still denied me for it although

the doc had given medical necseeity documentation.   Finally after about 2

months and threats of my lawyer they covered it.  In my experience, insurance

companies want

> nothing to do hypogonadsim or medication to treat it.    Hang in there

.          

My insurer recently told me that the medicare protocol is in office

shots. That influenced them to cover in office care - they'd

previously denied my claims because I wasn't self injecting - this at

an HMO where the Doc says go to the injection room!

[Guest guest]

Well as these things go...I had delayed sending the appeal in for the last

couple of weeks because they let me get one vial and I had the time. Dropped

the appeal in the outgoing mail yesterday, and today I get a letter from

Security Blue that I have been APPROVED for the Testosterone Enanthate. What a

strange world. And it STILL makes me mad that T require Prior Authorization and

all the female HRTs DON'T!!

Thanks to all for reading.

>

> >

> >Hi ,  I had a very similar situation with Highmark ( we must live in

the same region)  When I  initially began TRT it was thru self injections of

Delatestryl.    My doc the insurance would not pay for me to have this done

every 10 days thus I was trained on how to self administer the shots.    That

worked for about a year and  half until I had developed cellulitis from a bad

injection.   That caused me to spend a week in the hospital with IVs and nearly

losing my leg from the infection.   My doc then put me Androderm ( TRT

patch) but that caused burns and welts.   The only option left was Androgel.  

We had to fight like hell with Highmark since it is the most expernsive of the

TRTs out there.    The weasly, cheap bastards still denied me for it although

the doc had given medical necseeity documentation.   Finally after about 2

months and threats of my lawyer they covered it.  In my experience, insurance

companies want

> > nothing to do hypogonadsim or medication to treat it.    Hang in there

.          

>

>

> My insurer recently told me that the medicare protocol is in office

> shots. That influenced them to cover in office care - they'd

> previously denied my claims because I wasn't self injecting - this at

> an HMO where the Doc says go to the injection room!

>

[Guest guest]

I don't understand why Medicare would be involved at all if you self inject?

That would just be the drug coverage portion (schedule D). Depending on what

plan you bought and what drug tier Testosterone Cypionate falls under determines

how much you pay for it. " H. "

>

> >

> >Hi ,  I had a very similar situation with Highmark ( we must live in

the same region)  When I  initially began TRT it was thru self injections of

Delatestryl.    My doc the insurance would not pay for me to have this done

every 10 days thus I was trained on how to self administer the shots.    That

worked for about a year and  half until I had developed cellulitis from a bad

injection.   That caused me to spend a week in the hospital with IVs and nearly

losing my leg from the infection.   My doc then put me Androderm ( TRT

patch) but that caused burns and welts.   The only option left was Androgel.  

We had to fight like hell with Highmark since it is the most expernsive of the

TRTs out there.    The weasly, cheap bastards still denied me for it although

the doc had given medical necseeity documentation.   Finally after about 2

months and threats of my lawyer they covered it.  In my experience, insurance

companies want

> > nothing to do hypogonadsim or medication to treat it.    Hang in there

.          

>

>

> My insurer recently told me that the medicare protocol is in office

> shots. That influenced them to cover in office care - they'd

> previously denied my claims because I wasn't self injecting - this at

> an HMO where the Doc says go to the injection room!

>

[Guest guest]

Could be because Testosterone is a controlled substance. They frown on

self injection because of the potential for abuse.

On Tue, 21 Apr 2009 17:15:26 -0000, you wrote:

>I don't understand why Medicare would be involved at all if you self inject?

That would just be the drug coverage portion (schedule D). Depending on what

plan you bought and what drug tier Testosterone Cypionate falls under determines

how much you pay for it. " H. "

>

>

>>

>> >

>> >Hi ,  I had a very similar situation with Highmark ( we must live in

the same region)  When I  initially began TRT it was thru self injections of

Delatestryl.    My doc the insurance would not pay for me to have this done

every 10 days thus I was trained on how to self administer the shots.    That

worked for about a year and  half until I had developed cellulitis from a bad

injection.   That caused me to spend a week in the hospital with IVs and nearly

losing my leg from the infection.   My doc then put me Androderm ( TRT

patch) but that caused burns and welts.   The only option left was Androgel.  

We had to fight like hell with Highmark since it is the most expernsive of the

TRTs out there.    The weasly, cheap bastards still denied me for it although

the doc had given medical necseeity documentation.   Finally after about 2

months and threats of my lawyer they covered it.  In my experience, insurance

companies want

>> > nothing to do hypogonadsim or medication to treat it.    Hang in there

.          

>>

>>

>> My insurer recently told me that the medicare protocol is in office

>> shots. That influenced them to cover in office care - they'd

>> previously denied my claims because I wasn't self injecting - this at

>> an HMO where the Doc says go to the injection room!

>>

>

[Guest guest]

That is good news but keep all the letters on this it can come back on you when

your Dr. gives you a re full.

Co-Moderator

Phil

> From: Woolf <fkw1122@...>

> Subject: Re: Appeal Letter to insurance company that denied me

coverage..looking for feedback

>

> Date: Monday, April 20, 2009, 6:58 PM

> Well as these things go...I had delayed sending the appeal

> in for the last couple of weeks because they let me get one

> vial and I had the time. Dropped the appeal in the outgoing

> mail yesterday, and today I get a letter from Security Blue

> that I have been APPROVED for the Testosterone Enanthate.

> What a strange world. And it STILL makes me mad that T

> require Prior Authorization and all the female HRTs

> DON'T!!

>

> Thanks to all for reading.

>

>

>

>

> >

> > >

> > >Hi ,  I had a very similar situation with

> Highmark ( we must live in the same region)  When I 

> initially began TRT it was thru self injections of

> Delatestryl.    My doc the insurance would not pay for me

> to have this done every 10 days thus I was trained on how to

> self administer the shots.    That worked for about a

> year and  half until I had developed cellulitis from a bad

> injection.   That caused me to spend a week in the

> hospital with IVs and nearly losing my leg from the

> infection.   My doc then put me Androderm ( TRT

> patch) but that caused burns and welts.   The only

> option left was Androgel.   We had to fight like

> hell with Highmark since it is the most expernsive of the

> TRTs out there.    The weasly, cheap bastards still

> denied me for it although the doc had given medical

> necseeity documentation.   Finally after about 2 months

> and threats of my lawyer they covered it.  In my

> experience, insurance companies want

> > > nothing to do hypogonadsim or medication to treat

> it.    Hang in there .          

> >

> >

> > My insurer recently told me that the medicare protocol

> is in office

> > shots. That influenced them to cover in office care -

> they'd

> > previously denied my claims because I wasn't self

> injecting - this at

> > an HMO where the Doc says go to the injection room!

> >

>

>

>

>

> ------------------------------------

>

>

[Guest guest]

Thanks Phil,

According to customer support, the authorization is good through the year 2099

(although I know at worst it is an annual thing).

Oh, if anyone wants to use any part of my appeal letter, that's what I posted it

for (and for feedback at the time).

>

> > From: Woolf <fkw1122@...>

> > Subject: Re: Appeal Letter to insurance company that denied

me coverage..looking for feedback

> >

> > Date: Monday, April 20, 2009, 6:58 PM

> > Well as these things go...I had delayed sending the appeal

> > in for the last couple of weeks because they let me get one

> > vial and I had the time. Dropped the appeal in the outgoing

> > mail yesterday, and today I get a letter from Security Blue

> > that I have been APPROVED for the Testosterone Enanthate.

> > What a strange world. And it STILL makes me mad that T

> > require Prior Authorization and all the female HRTs

> > DON'T!!

> >

> > Thanks to all for reading.

> >

> >

> >