posted
Update at end of thread. -----------------------------
After another ER visit with hubby we found a message at the hotel saying the insurance company was denying all neuro tests for hubby because he did not have a brain tumor.
Waited 1 1/2 weeks already for tests to be scheduled and now it doesn't look like they will get done tomorrow after we changed hotels and made the drive of 1 1/2 hours to be closer to the hospital.
This is just more stress we didn't need right now.
ER doc and the neuro at the hospital agreed hubby needed the tests, but didn't do them today since they were already scheduled for tomorrow.
Seriously, what diagnoses did others use to get their brain SPECT scans approved by insurance?
I still can't believe they denied a brain MRI although I knew we would have trouble getting the lumbrosacral back MRI done.
If all else fails I may end up taking the advice of the customer service rep at the insurance company -- suggested I take hubby back to the ER and let them order the tests. Of course that would all be dependant upon finding an agreeable ER doc.
Tomorrow looks to be very very long day.
Bea Seibert
[ 06. February 2007, 01:09 AM: Message edited by: seibertneurolyme ]
Posts: 7306 | From Martinsville,VA,USA | Registered: Oct 2004
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posted
It was stressful enough listening to the ER doc and the neuro at the hospital discussing the fact that they think hubby has permanent brain damage based on symptoms.
Then finding out the tests will most likely be postponed was just the last straw.
Still hoping the SPECT shows hypoperfusion and/or vasculitis whenever it gets done. Would so like to show some docs that perisitent Lyme and tickborne infections do exist.
Hubby had very similar symptoms in the past which improved greatly with IV antibioitcs and quinine/clindamycin treatment for babesia.
Bea Seibert
Posts: 7306 | From Martinsville,VA,USA | Registered: Oct 2004
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Keep us posted, and stay strong, Bea. I'm so sorry about this news.
-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96222 | From Texas | Registered: Feb 2001
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Jill E.
Frequent Contributor (1K+ posts)
Member # 9121
posted
My heart just sank when I read your posts. I'm so sorry you're going through this.
I've cried many a time after talking to the insurance companies, even appealed decisions and many times had to pay out of pocket. But obviously, with brain scans, we're talking expensive.
I haven't had a SPECT so I will leave it to others to provide their expertise.
My insurance paid a portion of my spinal MRIs when my initial diagnosis was suspected MS. They only paid a drop in the bucket of my brain MRI once I had a Lyme diagnosis, even though one doctor was still trying to rule out MS.
I hope the ER docs will sign whatever authorizations are needed.
With Steve's tremors, I wonder if they would pay if you used a Parkinson's diagnostic code. Maybe someone here can speak to that.
Good luck, Bea.
Jill
-------------------- If laughter is the best medicine, why hasn't stand-up comedy cured me? Posts: 1773 | From San Diego | Registered: Apr 2006
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trails
Frequent Contributor (1K+ posts)
Member # 1620
posted
oh that stinks!!!
hope you have things to keep you occupied and comfy coz it does seem like it will be a LONG day.
I am so sorry. You deserve better
Posts: 1950 | From New Mexico | Registered: Sep 2001
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This is awful news! I can't understand the insurance company's reasoning.
I don't doubt that you will get your husband the tests he needs. I am just sorry that the insurance company is making things difficult.
Also, my insurance paid for a SPECT with a diagnosis of lyme, for a brain MRI as part of work up of poor short term memory , a spinal MRI for clonus on neurological exam, and a full body CT (including brain) for fatigue. I had BCBS of Massachsetts at that time. So, it's hard for me to fathom that your husband's tests would be denied. Don't give up.
You and your husband will be in my prayers.
Posts: 628 | From the south | Registered: Dec 2005
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Michelle M
Frequent Contributor (1K+ posts)
Member # 7200
posted
If anyone can 'give it back' to them, YOU can.
Not that you should have to.
I like the idea of the ER. That may work. People who are having seizures should not be an unexpected thing in the ER.
How about a 'medical necessity' dr. auth? Sometimes that makes it happen on a fast basis.
I too hate insurance companies.
Posts: 3193 | From Northern California | Registered: Apr 2005
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posted
Start the appeals process. Call your State Attorney General. Complain, complain, complain because the squeeky wheel gets the oil. I read that the CT State Atty. called an insurance company that was denying health benefits for one of his constituents. Soon afterward, the insurance company changed it's mind and paid for treatment.
Maybe call your state senator & and even a reporter. They can shine the spotlight on the insurance companies and always LOVE human interest stories. This one has all the right elements, suffering, people who are hurting, an insurance company denying treatment, a controversial disease...it can't hurt to make the call & give an interview to the ones most interested.
Kayda
Posts: 582 | From midwest | Registered: Nov 2006
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bettyg
Unregistered
posted
please keep this up to top; they need our thoughts and prayers today, 2-2-07, while tests are occuring. thanks everyone!
bea, i hate what they did to you especially to leave the message on the motel phone answering machine!
i love kay's idea; hope you will pursue that avenue especially getting ahold of the MEDIA; live coverage!
contacting your state's attorney general; " ": virginia's INSURANCE COMMISSIONER
since you have your laptop, while steve is getting tests done, get on their and contact the VIP folks who can help you!
May God carry you today thru the latest $$ hurdle you are going thru. "
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sometimesdilly
Frequent Contributor (1K+ posts)
Member # 9982
posted
Bea-
i missed this post by you, sorry.
posted in General too about a national patient advocay group to call:
1-800-532-5274. (Patient Advocacy Foundation)
Also, another angle for you to try with insurance company:
ask if BCBS outsources preauth work to another company (most do), find out company's name, and a SUPERVISOR's name there and phone number, and call directly.
It took a long time and lots of struggle to get my SPECT authorized-- i only realized after the fact that a huge chunk of time was wasted because the custmer service folk at Cigna knew NOTHING about SPECTS and speciality MRI's, because they didn't deal with them at all, ever, firsthand.
again, please let me know if there is anything at all i can do to help.
dilly
Posts: 2507 | From lost in the maze | Registered: Aug 2006
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posted
It's bad enough that a person needs to have these tests done, that's stressful enough. They.......... (ins. co.'s) act as though we don't have anything better to do than think up medical procedures for them to pay for. Sorry you have to go through this.
Posts: 158 | From PA. | Registered: Jul 2006
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trails
Frequent Contributor (1K+ posts)
Member # 1620
posted
YES! not that you have the time and the energry but contacting a local TV station about this can work very effectively! I got a large bill paid just by threatening this---NO JOKE! I told them which station I had called and they were reallllly upset as they had some recent good press.
I am thinking of you guys today!
Posts: 1950 | From New Mexico | Registered: Sep 2001
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bettyg
Unregistered
posted
up for prayer chain for steve and bea as he goes thru whatever tests today; they need our full support today and afterwards!
posted
From the sound of it, a physician tried to get a prior authorization for a SPECT and other tests, and it was denied by the health insurer.
Who is the health insurer in question?
A number of health insurers settled a class action lawsuit brought agianst them by physicians. the case was brought under RICO (organized crime)statutes. If your health insurer was one of the insurers who settled, it might make sense to ask the insurer to verify that their denial does not violate the physician settlement, and if they hesitate, offer to contact the physician attorneys to make absolutely sure that you are not involved in settlement violations...
I would also question the denial for the following reasons: 1. Generally, there are time deadlines for denials, and when the insurer misses a time deadline, the policyholder may get automatic authorization.
2. The denial was by phone. Generally, denials have to be in writing, and have to provide a sound medical reason that is based on valid medical/scientific evidence.
3. In some states, and per the physician settlement, denials have to be based on the medical evidence, and the medical evidence has to be denied by a qualified clinical peer. An insurance customer service rep does not qualify as a medical peer.
You should try to get: 1. the name and credentials of the physician reviewer.
2. get the denial in writing, and get the physicians signature
3. get the name of your health insurers state medical director.
4. Request a written copy of the medical evidence-i.e. studies used in the insurer's denial
5. Contact your insurance bureau if this involves a small business or individual plan.
6. If you don't get anywhere with the insurance bureau, you may want to contact your state AG. Better yet, have a local congressional office contact the Ag's office on your behalf.
It might also be very helpful to contact your state medical licensing board to find out whether insurance reviewers are A. practicing medicine, and B. whether or not they have to have a medical license in your state if they are conducting insurance reviews in that state. If there appear to be issues, point these out to your local congressional office or state rep.
Hope that this is helpful
nannie
Posts: 183 | From US | Registered: Feb 2004
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bettyg
Unregistered
posted
nannie, outstanding advise for bea and steve!
I think I have figured out what the insurance company was trying to accomplish. Hubby has 2 insurance policies -- he kept his private policy which covers ER's, office visits, meds and out patient tests. His Medicare policy covers hospitalizations only.
The 2 MRI's finally got done on Saturday but as an inpatient so Medicare has to pay the bill instead of the insurance company.
Bea Seibert
Nannie -- Glad you posted your info here also so others could benefit. Thanks to all who responded. We definitely have some creative thinkers on this site. Will probably need to put some of this advice to use if the SPECT scan ever gets done.
Posts: 7306 | From Martinsville,VA,USA | Registered: Oct 2004
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CaliforniaLyme
Frequent Contributor (5K+ posts)
Member # 7136
posted
Glad to hear that, you two are in my thoughts!!!
Warm wishes, Sarah
-------------------- There is no wealth but life. -John Ruskin
All truth goes through 3 stages: first it is ridiculed: then it is violently opposed: finally it is accepted as self evident. - Schopenhauer Posts: 5639 | From Aptos CA USA | Registered: Apr 2005
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bettyg
Unregistered
posted
up we go; at bottom of page 1!
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