health and disability info/ may find on CALDA disability forms

[Guest guest]

See if this looks helpful - it's posted on the CALDA website:

[Date]

[insurer]

[Address]

[Address]

[Address]

Re: Member Number:

Patient Name:

Provider:

Dates of Service:

To Whom It May Concern:

I am writing with respect to my physician’s [NAME OF PHYSICIAN] request

for [treatment requested] for me, which [insurer] has denied. It is

unclear

to me why the insurance company is denying this care given that my

physician

has already indicated its necessity in writing. Please be aware that by

under-treating this bacterial infection, I could develop an even more

virulent and protracted condition, just as one might do with any bacterial

infection.

I am aware that [insurer] follows the IDSA guidelines for the diagnosis

and treatment of Lyme disease. However, these guidelines are now under

legal

scrutiny due to a 1 ½ year-long investigation by CT Attorney General

Blumenthal. According to the Attorney General, the IDSA's 2006 Lyme

disease

guideline panel “allow[ed] individuals with financial interests—in drug

companies, Lyme disease diagnostic tests, patents and consulting

arrangements

with insurance companies—to exclude divergent medical evidence and opinionâ€

(for more information, see the attached press release regarding the

Attorney General’s findings) and further found that these guidelines are

routinely used by insurance companies, to restrict or deny coverage for

long-term

antibiotic treatment. More specifically, the IDSA intentionally excluded

evidence and blocked panel appointments and opinions supportive of the

diagnosis and treatment of chronic Lyme disease.

In addition, when faced with an investigation into its exclusionary

guidelines process, the IDSA sought to ‘independently corroborate’ its

guidelines with copycat guidelines of the American Association of

Neurology (AAN),

when the IDSA knew that the two panels shared several authors, including

the

chairman of both groups and worked on the guidelines at the same time. The

IDSA violated its own policy concerning conflicts of interest by allowing

panel members to serve on both the AAN panels and the IDSA panel.

Moreover, these guidelines and any other copycat guidelines that the IDSA

develops

with other organizations are inherently tainted by the same conflicts of

interests that plagued the IDSA panel.

In May, the IDSA agreed to have its guidelines reassessed under the

oversight of an independent arbiter, with a new panel free of conflicts of

interest. In these circumstances any delay or denial of care based on IDSA

guidelines or the “copycat†guidelines by an insurer would be improper,

and

knowingly doing so could constitute a pattern of bad faith claims

practices.

The Attorney General further stated that although the IDSA emphasized that

the 2006 IDSA Guidelines were “voluntary†and the “ultimate determination

of their application†should be made “by the physician in light of each

patient’s individual circumstances,†insurance companies like United

Healthcare, Health Net and Blue Cross of California use the guidelines to

justify

denial of reimbursement for long term antibiotic treatment. The use of

the IDSA guidelines by insurance companies to justify denial of care

defeats

the designation of the 2006 IDSA Guidelines as being “voluntary†and

ultimately takes the decision regarding medical treatment away from the

treating

physicians and may constitute bad faith.

There are two standards of care regarding the diagnosis and treatment of

Lyme disease. Both are published by the National Guidelines Clearinghouse’

s

(NGC), which promotes evidence based guidelines that insurers rely

upon._[1]_ (_aoldb://mail/aoldb://mail/<Waoldb://m_

(aoldb://mail/write/template.htm#_ftn1) ) One standard emanates from the

flawed IDSA Guidelines. The second standard, promulgated by the

International Lyme and Associated Diseases Society (“ILADSâ€)_[2]_

(_aoldb://mail/aoldb://mail/<Waoldb://m_

(aoldb://mail/write/template.htm#_ftn2) ) , relies more heavily on physician

discretion and

resolution of the illness to determine length of treatment. My treatment

should not be evaluated under one standard of care when there is a

respectable

body of literature that strongly supports my physicians’ diagnosis and

treatment of Lyme disease. [insurer] is not entitled to arbitrarily impose

a

different treatment standard that directly conflicts with the one under

which

I was treated. A decision by [insurer] to arbitrarily apply the standard

that allowed it to avoid payment would constitute a self-serving

selectivity in the use of evidence and a bias in decision-making to

financially

benefit the insurer.

[insurer’s] actions clearly violate the federal Patient’s Bill of Rights

and those of many states. The Bill of Rights provides the patient with the

right to fully participate in all decisions relating to my health care. I

exercised this right and chose to be examined, diagnosed and treated under

the standard of care as set forth in the ILADS Guidelines and followed by

many practitioners. [insurer] should not be permitted to evaluate my

claims under another set of guidelines. The decision of choice of medical

treatment was mine to make.

Although insurers prefer, for financial reasons, to cover only short term

treatment for Lyme disease, they are not entitled to dictate medical

treatment in order to improve their bottom lines. Those decisions should

be left

to the physician and the patient. Accordingly, I request that [insurer]

review my claim under the ILADS treatment guidelines and that any reviews

of

my claim go to a qualified doctor who treats late-stage Lyme disease

patients like me under the ILADS standard, which I have selected.

Sincerely,

[signature]

cc: [state] Attorney General

Enclosures:

May 1, 2008 Press Release, Connecticut Attorney General, Attorney General’

s Office Finds Flawed Lyme Disease Guidelines Process, IDSA Agrees to

Reassess, Install Independent Arbiter

Connecticut Attorney General's Office

Press Release

Attorney General's Investigation Reveals Flawed Lyme Disease Guideline

Process, IDSA Agrees To Reassess Guidelines, Install Independent Arbiter

May 1, 2008

Attorney General Blumenthal today announced that his antitrust

investigation has uncovered serious flaws in the Infectious Diseases

Society

of America's (IDSA) process for writing its 2006 Lyme disease guidelines

and

the IDSA has agreed to reassess them with the assistance of an outside

arbiter.

The IDSA guidelines have sweeping and significant impacts on Lyme disease

medical care. They are commonly applied by insurance companies in

restricting coverage for long-term antibiotic treatment or other medical

care and

also strongly influence physician treatment decisions.

Insurance companies have denied coverage for long-term antibiotic

treatment relying on these guidelines as justification. The guidelines are

also

widely cited for conclusions that chronic Lyme disease is nonexistent.

" This agreement vindicates my investigation -- finding undisclosed

financial interests and forcing a reassessment of IDSA guidelines, "

Blumenthal

said. " My office uncovered undisclosed financial interests held by several

of

the most powerful IDSA panelists. The IDSA's guideline panel improperly

ignored or minimized consideration of alternative medical opinion and

evidence

regarding chronic Lyme disease, potentially raising serious questions

about whether the recommendations reflected all relevant science.

" The IDSA's Lyme guideline process lacked important procedural safeguards

requiring complete reevaluation of the 2006 Lyme disease guidelines -- in

effect a comprehensive reassessment through a new panel. The new panel

will

accept and analyze all evidence, including divergent opinion. An

independent neutral ombudsman -- expert in medical ethics and conflicts of

interest,

selected by both the IDSA and my office -- will assess the new panel for

conflicts of interests and ensure its integrity. "

Blumenthal's findings include the following:

* The IDSA failed to conduct a conflicts of interest review for any

of the panelists prior to their appointment to the 2006 Lyme disease

guideline panel;

* Subsequent disclosures demonstrate that several of the 2006 Lyme

disease panelists had conflicts of interest;

* The IDSA failed to follow its own procedures for appointing the

2006 panel chairman and members, enabling the chairman, who held a bias

regarding the existence of chronic Lyme, to handpick a likeminded panel

without

scrutiny by or formal approval of the IDSA's oversight committee;

* The IDSA's 2000 and 2006 Lyme disease panels refused to accept or

meaningfully consider information regarding the existence of chronic Lyme

disease, once removing a panelist from the 2000 panel who dissented from

the

group's position on chronic Lyme disease to achieve " consensus " ;

* The IDSA blocked appointment of scientists and physicians with

divergent views on chronic Lyme who sought to serve on the 2006 guidelines

panel by informing them that the panel was fully staffed, even though it

was

later expanded;

* The IDSA portrayed another medical association'* The IDSA port

guidelines as corroborating its own when it knew that the two panels

shared

several authors, including the chairmen of both groups, and were working

on

guidelines at the same time. In allowing its panelists to serve on both

groups at the same time, IDSA violated its own conflicts of interest

policy.

IDSA has reached an agreement with Blumenthal's office calling for

creation of a review panel to thoroughly scrutinize the 2006 Lyme disease

guidelines and update or revise them if necessary. The panel -- comprised

of

individuals without conflicts of interest -- will comprehensively review

medical

and scientific evidence and hold a scientific hearing to provide a forum

for additional evidence. It will then determine whether each

recommendation

in the 2006 Lyme disease guidelines is justified by the evidence or needs

revision or updating.

Blumenthal added, " The IDSA's 2006 Lyme disease guideline panel undercut

its credibility by allowing individuals with financial interests -- in

drug

companies, Lyme disease diagnostic tests, patents and consulting

arrangements with insurance companies -- to exclude divergent medical

evidence and

opinion. In today's healthcare system, clinical practice guidelines have

tremendous influence on the marketing of medical services and products,

insurance reimbursements and treatment decisions. As a result, medical

societies

that publish such guidelines have a legal and moral duty to use exacting

safeguards and scientific standards.

" Our investigation was always about the IDSA's guidelines process -- not

the science. IDSA should be recognized for its cooperation and agreement

to

address the serious concerns raised by my office. Our agreement with IDSA

ensures that a new, conflicts-free panel will collect and review all

pertinent information, reassess each recommendation and make necessary

changes.

" This Action Plan -- incorporating a conflicts screen by an independent

neutral expert and a public hearing to receive additional evidence -- can

serve as a model for all medical organizations and societies that publish

medical guidelines. This review should strengthen the public's confidence

in

such critical standards. "

THE GUIDELINE REVIEW PROCESS

Under its agreement with the Attorney General's Office, the IDSA will

create a review panel of eight to 12 members, none of whom served on the

2006

IDSA guideline panel. The IDSA must conduct an open application process

and

consider all applicants.

The agreement calls for the ombudsman selected by Blumenthal's office and

the IDSA to ensure that the review panel and its chairperson are free of

conflicts of interest.

Blumenthal and IDSA agreed to appoint Dr. A. Brody as the

ombudsman. Dr. Brody is a recognized expert and author on medical ethics

and

conflicts of interest and the director of the Institute for Medical

Humanities at

the University of Texas Medical Branch. Brody authored the book, " Hooked:

Ethics, the Medical Profession and the Pharmaceutical Industry. "

To assure that the review panel obtains divergent information, the panel

will conduct an open scientific hearing at which it will hear scientific

and

medical presentations from interested parties. The agreement requires the

hearing to be broadcast live to the public on the Internet via the IDSA's

website. The Attorney General's Office, Dr. Brody and the review panel

will

together finalize the list of presenters at the hearing.

Once it has collected information from its review and open hearing, the

panel will assess the information and determine whether the data and

evidence

supports each of the recommendations in the 2006 Lyme disease guidelines.

The panel will then vote on each recommendation in the IDSA's 2006 Lyme

disease guidelines on whether it is supported by the scientific evidence.

At

least 75 percent of panel members must vote to sustain each recommendation

or it will be revised.

Once the panel has acted on each recommendation, it will have three

options: make no changes, modify the guidelines in part or replace them

entirely.

The panel's final report will be published on the IDSA's website.

ADDITIONAL FINDINGS OF BLUMENTHAL'S INVESTIGATION

IDSA convened panels in 2000 and 2006 to research and publish guidelines

for the diagnosis and treatment of Lyme disease. Blumenthal's office found

that the IDSA disregarded a 2000 panel member who argued that chronic and

persistent Lyme disease exists. The 2000 panel pressured the panelist to

conform to the group consensus and removed him as an author when he

refused.

IDSA sought to portray a second set of Lyme disease guidelines issued by

the American Academy of Neurology (AAN) as independently corroborating its

findings. In fact, IDSA knew that the two panels shared key members,

including the respective panel chairmen and were working on both sets of

guidelines a the same time -- a violation of IDSA's conflicts of interest

policy.

The resulting IDSA and AAN guidelines not only reached the same

conclusions regarding the non-existence of chronic Lyme disease, their

reasoning at

times used strikingly similar language. Both entities, for example, dubbed

symptoms persisting after treatment " Post-Lyme Syndrome " and defined it

the

same way.

When IDSA learned of the improper links between its panel and the AAN's

panel, instead of enforcing its conflict of interest policy, it

aggressively

sought the AAN's endorsement to " strengthen " its guidelines' impact. The

AAN panel -- particularly members who also served on the IDSA panel --

worked

equally hard to win AAN's backing of IDSA's conclusions.

The two entities sought to portray each other's guidelines as separate and

independent when the facts call into question that contention.

The IDSA subsequently cited AAN's supposed independent corroboration of

its findings as part of its attempts to defeat federal legislation to

create

a Lyme disease advisory committee and state legislation supporting

antibiotic therapy for chronic Lyme disease.

In a step that the British Medical Journal deemed " unusual, " the IDSA

included in its Lyme guidelines a statement calling them " voluntary " with

" the

ultimate determination of their application to be made by the physician in

light of each patient's individual circumstances.light of each

Healthcare, Health Net, Blue Cross of California, Kaiser Foundation Health

Plan and

other insurers have used the guidelines as justification to deny

reimbursement for long-term antibiotic treatment.

____________________________________

_[1]_ (_aoldb://mail/aoldb://mail/<Waoldb://mail_

(aoldb://mail/write/template.htm#_ftnref1) ) , L. B. and R. B.

Stricker (2004). " Treatment of Lyme disease--a medicolegal assessment. "

Expert Rev Anti-infect Ther 2(4): 533-57.

_[2]_ (_aoldb://mail/aoldb://mail/<Waoldb://mail_

(aoldb://mail/write/template.htm#_ftnref2) ) The International Lyme

and Associated Diseases Society (2004). " ILADS Evidence-

based guidelines for the management of Lyme disease. " Expert Rev.

Anti-infect. Ther. 2(1): S1–S13.

Sheila M. Statlender, Ph.D.

Clinical Psychologist

53 Langley Road - Suite 330C

Newton Centre, MA 02459

617-965-2329

In a message dated 2/25/2010 1:53:29 P.M. Eastern Standard Time,

_tammyadams1968@tammyadam_ (mailto:tammyadams1968@...) writes:

My insurance company just sent me a denial for IV antibiotics for my

Daughter it states:

Per MD Review not medically necessaary. Patient has had extensive

essentially unprecedented therapy with intravenous antibiotics numerated

in the

documnts submitted. despite her physician's claim of response, which in

fact

may be true, the prescribed antibiotic therapy

for lyme disease is unique and not conform to accepted standards of care.

Infact one has to be concerned if the detriments of such therapy as well.

Our MD Reviewer did call and discuss her case with her doctor.

I am looking for Information about the IDSA guidelines and the conflict

of interest and any other weapon I could use, such as the recent states

allowing Aggresive Lyme Treatments.

My daughter went undiagnosed for 6 years, lyme disease/bart/My daughter

went undiagnosed for 6 years, lyme disease/bart/<WBR>babs have affected

her

brain

If anyone can help us fight with any information please contact me as

soosoon as possible

Thanks in advance

Tammy

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