Re: medications denied

March 28, 2002

Kathleen,

The insurance companies are used to " bullying " around their clients because

they can. If I were you, I would get in touch with a good medical attorney. To

me, it would be worth the cost to get the eventual relief from pain. Not to

mention the satisfaction of not letting cigna screw with you! Krysi

March 28, 2002

Kathleen, you might ask the doctor for some samples of the pain medication,

while you appeal this.

My mom does this, because her meds often cost $1-2 a pill if it's not

covered by insurance or Medicare.

Good luck!

NB

medications denied

> hi all-

> well finally have a good pain doctor and now my insurance refuses to

cover

> my prescriptions. the prescribed medications are covered by my plan just

> that the prescriptions are not OKayed for me.

March 28, 2002

Kathleen,

My heart so goes out to you!!!! You sound in a desperate place and I plead

with you to just hold on. You could purchase the patches out of pocket, but

I know that's costly. Still, if you could feel better and turn your energy

against Cigna, maybe the cost would be justified. I do like the idea of an

attorney. These insurance companies can be @#@**. I deal with them through

the hospital daily, trying to get benefits approved, etc. I swear I'm going

to start a business fighting their injustices. Good luck to you.

Donna

>

March 28, 2002

This may be a simple problem of what diagnosis or diagnosis code your

doctor is using. If he is just using a generalized all-purpose

diagnostic code for pain, such a strong medicine might not be

approved. He needs to find an appropriate code number for your

condition which your insurance company approves for this medication.

If it was approved for you two years ago by the other doctor such a

code apparently exists. This is something you should discuss with

the doctor or his insurance person. It is not necessarily a question

of fighting the insurance company but rather understanding their

system and the kinds of diagnoses for which they will approve

particular medicines.

I am going through something similar now. After I got home from the

hospital following my surgery, a home health care company was sending

a physical therapist to my home 3 times a week. This was ordered and

arranged for by the hospital. I found out that my insurance company

denied the claim from the home health care company because of the

initial diagnosis code used but someone at the insurance company took

an interest and asked the therapists for their case notes. After

the " medical analyst " reviewed the notes the claim was paid. After

several weeks of home therapy the physical therapists felt I had

improved to the point where they could no longer justify coming to my

home but they thought it would be beneficial to continue at their

premises where I could use some of their equipment. The problem was

that changing the venue required a new evaluation and submission of a

different claim. To avoid problems down the road, the insurance

company advised me that I find out from the physical therapist what

code number he would use in the billing so they could tell me in

advance whether or not it would be approved. It turned out that the

physical therapist knew nothing about the codes and the only thing he

could come up with was the code for scoliosis. However, I already

knew they would not approve this code because scoliosis is a chronic

condition and I had read in my policy that it does not cover physical

therapy for chronic conditions. I told him this and also pointed out

that the therapy was not for the scoliosis but rather to help me

recover from the surgery. Unfortunately he didn't know any other

codes to use. At that point, I called the insurance company and gave

them the scoliosis code. After the expected response that that would

not be payable, in exasperation I said, " why can't we just assign the

same codes as when they were coming to my house since it's just a

continuation of that. " The answer was that when the home health care

agency billed, the successful claim that was finally paid used 3

different diagnosis codes only one of which was payable. However,

the insurance company representative I was speaking with was not

permitted to tell me the three codes much less the one that was

payable. I then spoke to the biller at the physical therapy company

thinking she would know more about this but she told me to call the

home health care agency to find out what codes they had used. This

is obviously a ridiculous situation. The insurance company paid for

my A/P surgeries, many hospital visits by consultants because of

complications, 3 weeks in the surgical hospital and 3 weeks in a

rehab hospital. They know exactly what was done to me and why I need

physical therapy. Nevertheless, despite their huge investment in my

surgery they apparently don't mind if I don't regain my strength to

walk properly by continuing the physical therapy program. This is

supposed to be " managed care, " but if it were managed in any

meaningful sense of the word, it seems to me the follow-up post-

surgical rehabilitation would be pretty important.

The lesson is that the key to this system is for the doctor to find

the right code. In the case I am describing, the physical therapist

should probably be billing under some variant of " spinal fusion

surgery " which the insurance company would recognize as a limited

situation from which I will recover in a relatively short period of

time rather than " scoliosis " which is viewed as a chronic condition

for which the insurance company thinks physical therapy will not be

beneficial. But the way the system works could drive a healthy

person crazy to say nothing of the effect on people who are

recovering from huge surgeries and/or in great pain.

My new doctor runs a

thriving well traineed ambulatory center and he called me and said I

must

try this drug it is the right one for my situation and he can't be

fighting

my insurance company for me. Which means sort it out or I'm

out....well

thats how I understood it.

March 28, 2002

dear kathleen,

please don't give up! your family needs you too much! Do you have anyone in

your family or immediate family that would pay for your prescription so that you

aren't going thru with-drawal symptoms? then, have you tried asking to speak

with the cigna (cigna a--holes) clerks supervisors? the clerks are trained to

deny deny deny everything. you need to let the pain management MD know that you

need some help getting pre-authorization. It isn't the MD that has to call your

insurance, it is his clerk's job to obtain the pre-authorization. I feel so

badly for you, I am just now wearing the duragesic patch myself and finally am

able to stand up and walk to the kitchen to eat with my family at the counter.

I am fused from c3-c7 and t1-l4. I found a great neurologist to diagnose my s/p

scoliosis with rod, rod removal, spinal cord injury l3-s1. Do you have a good

neurologist? do you have a good primary scoliosis MD? do you have medicare? I

am getting the pump as soon as I can, My insurance will pay for the pump and

medicine after medicare pays the 80%. I feel as though it is all too good to

be true. I won't get my hopes up too high for just that same reason. where do

you live? I live in FL. I will check back on my e-mail Monday, if not before.

don't give up!! would you MD prescribe you something for the vomiting? or at

least wean you off gently by decreasing oral oxycontin by 10mg per week? you

would be in pain, but not barfing your guts out. I will keep in touch and try

to find out on my end what can be done. londa2612@...

Kathleen Wigham <kulina@...> wrote: hi all-

well finally have a good pain doctor and now my insurance refuses to cover

my prescriptions. the prescribed medications are covered by my plan just

that the prescriptions are not OKayed for me. Isn't that descrimination. the

doc wrote the scripts and then had to call the Cigna clerks etc. They say I

don't fit the criteria guidelines for the Duragesic Patch/Fentynal. They

won'tI had my hopes and my heart all happy and finally after suffering for

four years I actually thought i'd havea relatively pain free life within a

few weeks. I stupidly started dreaming of taking my kids to the zoo and the

Metropolitan museum and all kinds of adventure. I believed my life would get

started again until today when I tried to have the prescription

filled.mCIGNA those bastards cover Duragesic medication but it apparently

requires prior authorization. So after my doctor's office contacted them

twice I called Cigna and they said my prescription was denied because I

haven't met " THE CRITERIA " FOR APPROVING FOR me TO HAVE THIS PAIN RELIEVING

DRUG. I fought and cried and got sick and just feel hopeless again. They

will not tell me ehat criteria needs to be met nor will they allow me to

talk to the person who denied the prescription. My new doctor runs a

thriving well traineed ambulatory center and he called me and said I must

try this drug it is the right one for my situation and he can't be fighting

my insurance company for me. Which means sort it out or I'm out....well

thats how I understood it. its basically try this avenue of meds or a

morphine pump is right next in line. I'd rather not have another foreign

body put in my body! Duragesic is a covered med in my plan BUT not for me to

have access to. Cigna won't explain their decision and they say they don't

have to!!! SSSOOOOOOO I finally find someone who knows what I am talking

about and all of my medical conditions. I signed myself to only him

prescribing any narcotics and I had severed my previous pain doc. in order

to sign on with a new one which is common. But now I am starting off my

relationship with my new doctor on a bad and angry beginning. No one at

cigna will tell me what the criteria are so I don't know what I am fighting

to appeal their decision. Anyone else have any tips. I threatened them that

I am in between pain doctors and if anything anything happens to me they are

going to be held liable. What can I do??? I'm sick to my stomach hurting

more and totally shattered and depressed and don't want to cope or deal with

anything. Gosh.. thanks for letting me vent and any helpful direction would

be greatly appreciated. worn out and have had it with my life today. If I

could climb up outside and build a giant sign saying CIGNA sucks I would do

so and proudly display it!

I guess this was just too good to be true. I met and felt so good about the

pain managment regimen this doctor wants to begin.....now I am being

discriminated gainst. What is even more absurd they paid for it TWO years

ago!!!!!

I really want to get in my van and run away,.. forget who I am... sit on a

park bench drooling and in a stupor not knowing ir caring about anything

going on around me. I'm so hit bottom. I'm so fed up of having to fight for

everything. Its just icing on the cake. Two weeks ago I had mass discovered

in my right lung.. node size like whatever that means. They refused to

approve the cat scan because I had had catscans within the last three

months. Never mind the fact it was for my chest not my neck or back

didn't mean anything to them JUST no..you've had too many. Obviously it did

no good because they are idiots. Anyone with any helpful tidmits PLEASE GET

THEM TO ME. i'M NOW DESPERATE AND SO SAD.

thank you

TwistedSister in NJ

t

** LIFE IS UNCERTAIN....EAT DESSERT FIRST **

" Harrington Rod people and other post-op multiple spine surgery people may

be interested in the following website dedicated to flatback syndrome and

multiple spine surgery cases: " Salvaged Sisters of Scoliosis " website

http://forums.delphiforums.com/adultscoliosis/messages

March 28, 2002

Dear Kathleen,

It sounds like you are going through so much....you have my warmest thoughts at

this time. I am

concerned about the pain you are in but also about them denying you a cat scan

for a mass in your

lung..that would be enough to frighten me as well. It sounds like you need local

advocates for

you. It is possible they are using incorrect codes and that they are linking up

the request for

the catscan with the reason for the priors as opposed to a separate issue.

Do you have family or friends that could go to bat for you, bring to

appointments , make calls

etc..

Please hold on and get some assistance locally as well as this group. You need

that support ..is

there a local scoliosis group or the natl scoliosis group.

It makes me so mad and so sad that insurance controls so much of our lives and

often makes

horrendous decisions...my heart goes to you and I hope this gets resolved for

you soon. Best,

Jessie

--- Kathleen Wigham <twistedsister_33@...> wrote:

> hi all-

> well finally have a good pain doctor and now my insurance refuses to cover

> my prescriptions. the prescribed medications are covered by my plan just

> that the prescriptions are not OKayed for me. Isn't that descrimination. the

> doc wrote the scripts and then had to call the Cigna clerks etc. They say I

> don't fit the criteria guidelines for the Duragesic Patch/Fentynal. They

> won'tI had my hopes and my heart all happy and finally after suffering for

> four years I actually thought i'd havea relatively pain free life within a

> few weeks. I stupidly started dreaming of taking my kids to the zoo and the

> Metropolitan museum and all kinds of adventure. I believed my life would get

> started again until today when I tried to have the prescription

> filled.mCIGNA those bastards cover Duragesic medication but it apparently

> requires prior authorization. So after my doctor's office contacted them

> twice I called Cigna and they said my prescription was denied because I

> haven't met " THE CRITERIA " FOR APPROVING FOR me TO HAVE THIS PAIN RELIEVING

> DRUG. I fought and cried and got sick and just feel hopeless again. They

> will not tell me ehat criteria needs to be met nor will they allow me to

> talk to the person who denied the prescription. My new doctor runs a

> thriving well traineed ambulatory center and he called me and said I must

> try this drug it is the right one for my situation and he can't be fighting

> my insurance company for me. Which means sort it out or I'm out....well

> thats how I understood it. its basically try this avenue of meds or a

> morphine pump is right next in line. I'd rather not have another foreign

> body put in my body! Duragesic is a covered med in my plan BUT not for me to

> have access to. Cigna won't explain their decision and they say they don't

> have to!!! SSSOOOOOOO I finally find someone who knows what I am talking

> about and all of my medical conditions. I signed myself to only him

> prescribing any narcotics and I had severed my previous pain doc. in order

> to sign on with a new one which is common. But now I am starting off my

> relationship with my new doctor on a bad and angry beginning. No one at

> cigna will tell me what the criteria are so I don't know what I am fighting

> to appeal their decision. Anyone else have any tips. I threatened them that

> I am in between pain doctors and if anything anything happens to me they are

> going to be held liable. What can I do??? I'm sick to my stomach hurting

> more and totally shattered and depressed and don't want to cope or deal with

> anything. Gosh.. thanks for letting me vent and any helpful direction would

> be greatly appreciated. worn out and have had it with my life today. If I

> could climb up outside and build a giant sign saying CIGNA sucks I would do

> so and proudly display it!

> I guess this was just too good to be true. I met and felt so good about the

> pain managment regimen this doctor wants to begin.....now I am being

> discriminated gainst. What is even more absurd they paid for it TWO years

> ago!!!!!

> I really want to get in my van and run away,.. forget who I am... sit on a

> park bench drooling and in a stupor not knowing ir caring about anything

> going on around me. I'm so hit bottom. I'm so fed up of having to fight for

> everything. Its just icing on the cake. Two weeks ago I had mass discovered

> in my right lung.. node size like whatever that means. They refused to

> approve the cat scan because I had had catscans within the last three

> months. Never mind the fact it was for my chest not my neck or back

> didn't mean anything to them JUST no..you've had too many. Obviously it did

> no good because they are idiots. Anyone with any helpful tidmits PLEASE GET

> THEM TO ME. i'M NOW DESPERATE AND SO SAD.

> thank you

> TwistedSister in NJ

> t

> ** LIFE IS UNCERTAIN....EAT DESSERT FIRST **

> " Harrington Rod people and other post-op multiple spine surgery people may

> be interested in the following website dedicated to flatback syndrome and

> multiple spine surgery cases: " Salvaged Sisters of Scoliosis " website

> http://forums.delphiforums.com/adultscoliosis/messages

>

March 29, 2002

Kathleen,

Are you able to switch insurance companies? Are you able to get on

disability because you can get on Medicaid, and if a doctor writes a

prescription for some kind of drug, they have to pay for it. Sounds to me

that CIGNA is a cheap company and don't care what might happen to the

patient.

Hope things go much better,

Betty

Madison, WI

April 13, 2002

Kathleen,

I am not sure if you have been able to solve your problems concerning

insurance coverage, but I hope that you have been able to have some

relief from your pain. In case you haven't had any luck getting your

coverage, I am sending you two useful sites. The one for the state

of NJ is the page where you can file a complaint against your

insurance company with the state insurance board. (I used to work for

an insurance company and believe me, they pay attention to

complaints!)

Also, I have included the site of a lawyer who specializes in HMO,

insurance issues. His site has tons of information and resources

that may help you out, (and are cheaper then an attorney).

http://www.state.nj.us/dobi/enfcon.htm

http://www.truemanlaw.com/

I too have had surgery for scoliosis and now have chronic pain. I

had a Harrington Rod from T5-L3 in 1975 and my pain started around

1995. In 2000, I had an additional fusion at L5-S1 for unstable

spondylolisthesis, (spine sliding forward) and I have tried about

everything there is for pain. I went to a pain program that was

based on cognitive behavior therapy and it has helped me to cope with

the pain but it did not change it. I was using oxycontin with

roxicodone for breakthrough but have recently been changed to

methadone. I know that I will never have a minute without pain but I

am able to function and spend good time with my kids, (12 & 8). I

have to plan my day and make sure I have time for lying down and

using ice but I still go to all of there school and sports.

Good luck with your pain and the insurance. Feel free to email me if

you would like to talk.

Sherri

April 18, 2002

Dear Kathleen,

What's currently going on wiht your medications? Have you found any help?

Love, Londa another scoli sister