Re: IV DENIED

[Guest guest]

Joan

appeal,appeal,appeal

besides that get ur elected officals involved ....the department of

health....call a lawyer (ira maurer may help) tell oxford u plan to

sue........do what ever u have to.....

Reid

[Guest guest]

Hi Guys,

Well, I got the expected bad news today...the b*stards at Oxford denied

my LLMD's request for IV ABX for me!

I guess over 10 yrs. of tickbites, every Lyme Symptom on the list, 4

bands on the WB, and moderate to severe hypoperfusion and white matter

damage didn't matter.

Does anybody know what IT TAKES TO BE APPROVED? Should I switch

insurance companies...or will they all reject my claim?

I had been on oral abx for 7 months with no improvement, so my LLMD took

me off them to see how I'd feel. I guess they were doing something,

because my neurological sx have gotten much worse, and the headaches are

back. Should I do a LUAT and WB after I've been off abx for a month or

so???

, what are you going to do? Do you have any positive tests? And

Marta, I know that you're going through the same thing...do you know

what it will take for you to be approved?

I am so p*ssed off about this.....

Joan

1st Known Deer Tick Bites & Sx: '85

1st (Neg): '89

Cont'd Sx, Neg. s & No LD Dx: '90-'99 1st WB: 4+ Specific Bands:

4/99

Late Neuro-LD Dx: 6/99

[Guest guest]

in mass we have masshealth.

the kids are covered. we pay a small monthly fee and anything the insurance

doesn't cover (NOTHING!) they pay.

kay

[Guest guest]

Hi Joan,

I am still waiting to get one more test done before my doctor approaches

Prudential for my IV....I don't blame you for being PO'd, I am too for you.

I would recommend that you appeal, that is what I plan to do, I assume it is

similar to disability or SSDI, I was initially turned down for both of

those, but was eventually approved on appeals. Here is something that may

help you scroll down this is long:

<<How do you fight an HMO to grant referral out of network??? >>

Managed Care Central

http://www.familiesusa.org/managedcare/

State Health Insurance Contacts

http://www.naic.org/consumer/state/member.htm

Fight Your HMO!

http://www.bright.net/~ewp/fight_your_hmo.html

Informal Guide to Appealing Health Insurance

http://users.aol.com/jasonwolff/hmohelp.htm

The National Health Insurance Action Network

http://www.his.com/~pico/nhian.htm

HARP Home Page

http://www.harp.org/

and

You can fight your insurance company and win

The author of this article preferred to remain anonymous.

Patients must often do battle with their insurance companies. In one

case, the patient's company hired two consultants to dismiss her Lyme

diagnosis. She was frantic, not knowing how to fight them. Whatever you

decide to do, and no matter what the basis of your denial may be, make sure

that you READ YOUR POLICY.

There may be a specific procedure for appealing denials and you must follow

it. Be aware of time limits. Also see if they specify a time limit for

their response to your appeal. If you don't follow procedure, some

companies will simply ignore you and hope that you will go away, or that the

time limit for you to file properly will expire. Sometimes there is no

choice but to hire an attorney.

I had a problem in New Jersey which I feel is fairly universal. This

article will describe my strategy for beating your insurance company at

their game of denying you benefits for your legitimate medical needs.

The tactic that the insurance carriers use is typically something such

as: " It is the opinion of consultants that the treatment provided is

experimental and does not fall within the scope of your coverage.... " or,

" It is the opinion of our consultant that adequate treatment of (usually 28)

days has been provided. There is no indication for additional

treatments... " or, " The drug is not approved for Lyme disease.... "

Your response to this must be in stages in order to set up the paper

trail. Don't accept a " no " from an employee with no authority to say " yes. "

Deal with the decision makers, not the clerks. Keep copies of all your

correspondence.

Your first letter.

Respond with an appeal letter stating that you have performed a review of

the peer-reviewed medical literature and have found the following:

a. There is no clear consensus as to what constitutes appropriate or

adequate treatment for LD. There is no gold standard. The treating

physician's clinical decision must be regarded as acceptable in each

individual case.

b. While some of the literature does indicate successful treatment after

28 to 56 days in cases of early infection, there is a vast amount of support

in the literature for prolonged antibiotic therapy in cases of chronic LD,

multi-system infection, and especially neruoborreliosis.

c. Surely your consultant must be aware of these references. If s/he is

not, I will provide them for you.

Either you will get no response at all, or you will get another denial.

It is time for your second letter.

Your second letter.

a. With your second letter, provide specific references (For a

bibliography of 50 articles supporting the notion of persistent infection

despite antibiotic treatment send $1.00 and SASE to the Lyme Times Editor,

PO Box 1423, Ukiah, CA 95482.)

b. Demand to know the name of the consultant and the references s/he

cites in arriving at his/her conclusions, which deny your claim.

c. Copy everything to the insurance commissioner of your state with a

letter stating that your insurance carrier has violated its contractual

agreement with you and has denied you benefits for medically necessary

treatment, despite your having met your obligations by paying all your

premiums on time. Make sure you letter to the insurance company has " cc

(Name) Insurance Commissioner " at the bottom.

Your third letter.

Write another letter stating to the insurance company:

1. My claim has been denied on the basis of a selective review of the

literature which has been carefully selected to support the bias of your

consultant in order that s/he may recommend denial of my claim for medically

necessary treatment.

2. The denial of coverage was arbitrary and capricious and was not

based on the available medical literature. It is apparently the personal

opinion of the consultant. It is obvious that this tactic was used only for

the financial benefit of (Name of the insurance company), his/her employer.

Your denial of coverage has caused me great stress and personal harm.

3. Based on this, and due to your recalcitrant position in failing to

honor your contractual agreement with me, I have done (or will do) the

following:

a. File a formal complaint with the commissioner of insurance.

b. File suit against the insurance company for breach of contract in

which I will seek punitive damages.

c. Contact the state attorney general in order that a federal

investigation of possible racketeering may be instituted against both the

insurance company and consultant.

d. File a civil action against your consultant or consultants, their

employers and all associated individuals for personal harm. I have been

informed that their actions will not be protected by their malpractice

insurance as I have made available to them a multitude of citations from the

medical literature in support of the need for my treatments. They have

ignored the accepted medical literature in order to perpetrate a fraudulent

assessment of my medical condition for their own financial gain. I have

consulted with counsel and am assured that my suit will be successful and

likely to incite others to a major class action suit against these

consultants personally and you as a licensed company in this state.

e. You have 10 days to respond.

I have a series of letters in my office in which I have done essentially

as I have described above. Recently $17,000.00 in past due medical bills

were paid.

(This article is from the April/May 1997 issue of the Lyme Times)

Also, check out Art Doherty's website for articles and abstracts about

persistence in LD, I wish you luck,don't give up fighting, that is what they

want.

Hugs,

Marta

> From: Namkrats3@... (Joan)

>

> Hi Guys,

> Well, I got the expected bad news today...the b*stards at Oxford denied

> my LLMD's request for IV ABX for me!

[Guest guest]

Hi Marta and All,

Thanks for all the info on how to appeal...I really appreciate it! Now,

if I could just get my brain to work...

Got my " Official " certified denial letter from Oxford today. (Comments

in parenthesis are mine...)

" The requested procedure will not be covered for the following reasons: "

" Medical criteria for IV therapy for Late Stage Lyme Disease is not met "

(we're ignoring your Infectious Disease Specialist's diagnosis);

" There is no history of early Lyme Disease " (well, DUH! It took me ten

years to be dx'd...by then it was no longer EARLY!),

" No objective physical findings " (Oh my God, I guess none of my

arthritic, cardiac, neurological, etc, etc, etc, problems qualify),

" and negative serology " ( only 4 bands on IGG WB...oh well, I'll have to

try for the " magic 5 " )!

If this is a joke, it's not funny!

Marta, I wish you all the luck in the world that your PET Scan will

provide your ins. co. wth the proof that need to treat you with IV abx.

Geez, shouldn't 3 brain lesions be enough proof?!!!

Still P.O.'d.

Joan

[Guest guest]

Hi Reid,

I'm going to see my LLMD on the 24th and will discuss what I will have

to do to win an appeal. He told me that as things are now, I won't

win...but he is behind me and we just have to figure out what to do.

Thanks :-)

Joan

[Guest guest]

In a message dated 1/14/00 3:42:32 AM Eastern Standard Time,

mlmccoy@... writes:

<< Just keep in mind that they will almost always deny any

claim, and it is up to you to do your best to appeal. If you are not

feeling well enough, talk to your doctor too. >>

Exactly....get a copy of the denial...and EXACTLY what your Dr. DID send

in...often they do not have the time to completely document EVERYTHING...also

if I were you...I would get copies from various places that state Lyme is a

CLINICAL diagnosis...Art D. makes it very easy to go to his site and pick and

choose pertinent articles to print out and attach to any letter requesting

review...insurance companies often deny for the sake of denying.

....I always made SURE to get pre-approvals EVERY TIME a member of my family

went to the ER...and EVERY time it was rejected first go around stating,

" pre-authorization " from the primary was not received...

..one time I called my Dr. from the ER parking lot to get the approval b4 i

would walk in the door...

It is the easiest method to put off paying for medical care they

have...blanketly deny everything the first time it is submitted...B

[Guest guest]

Hi Joan and all,

Sorry the denial from Oxford was so devastating, they are pretty stupid,

don't you think? Just keep in mind that they will almost always deny any

claim, and it is up to you to do your best to appeal. If you are not

feeling well enough, talk to your doctor too. Most likely you will have to

be sent to one of their doctors...and you know who that will be: Sigal,

Steere, et c. but if so that's good, then you can file complaints against

them. I did get a call yesterday from Doctors office, they are now working

on the pre cert for the P.E.T. scan, it takes time I guess. I guess three

lesions could be MS, thus the doctor wants the PET Scan????

Please keep us all posted on your progress, so sorry you have to go through

this BS.

Big Hugs,

Marta

> From: Namkrats3@... (Joan)

>

> Hi Marta and All,

> Thanks for all the info on how to appeal...I really appreciate it! Now,

> if I could just get my brain to work...

>

> Got my " Official " certified denial letter from Oxford today. (Comments

> in parenthesis are mine...)

>

> " The requested procedure will not be covered for the following reasons: "

>

> " Medical criteria for IV therapy for Late Stage Lyme Disease is not met "

> (we're ignoring your Infectious Disease Specialist's diagnosis);

>

> " There is no history of early Lyme Disease " (well, DUH! It took me ten

> years to be dx'd...by then it was no longer EARLY!),

>

> " No objective physical findings " (Oh my God, I guess none of my

> arthritic, cardiac, neurological, etc, etc, etc, problems qualify),

>

> " and negative serology " ( only 4 bands on IGG WB...oh well, I'll have to

> try for the " magic 5 " )!

>

> If this is a joke, it's not funny!

>

> Marta, I wish you all the luck in the world that your PET Scan will

> provide your ins. co. wth the proof that need to treat you with IV abx.

> Geez, shouldn't 3 brain lesions be enough proof?!!!

>

> Still P.O.'d.

> Joan

>

[Guest guest]

In a message dated 1/13/00 8:30:19 PM Eastern Standard Time,

Namkrats3@... writes:

<< He told me that as things are now >>

GET copies of EVERYTHING,

today...call the doctor's office people and ask them to copy everything for

you

and read it all for yourself, and put together an appeal package...if you

need help holler....also...do ya know ANY lawyers...a friend of mine accepted

10cent retainer from me...and told me to CC ANYTHING I sent to his name

followed by Esq. denoting to the comapny you have engaged a lawyer...

I was lucky not to have to use his offer to use his name and if needed... use

his help...but while you are resting...try to sort out and organize your

options....b

[Guest guest]

Dear Bernadette,

Thank you for all of the info. We can always count on you for good info

and advice. :-)

I am extremely tired today, but will write more soon. Going on vacation

next week...hope I have some energy to enjoy it.

Thanks Again,

Joan