posted
I just received a call from my LLMDs office. Insurance company (Health Net) denied PICC Line IV treatment.
LLMD will appeal and arrange peer-to-peer review; however, unlikely to get approval.
Insurance company said I did not meet CDC criteria as well as I have not been on the "right" antibiotics (although they did not suggest what antibiotics I SHOULD be on).
Insurance company wants me to be on oral antibiotics for a longer term of treatment.
I have been in treatment since April 2010 (after being misdiagnosed by my MD for 5+ years).
Have tried all sorts of antibiotic/s combinations; some slight relief; but not better.
Anyone win an appeal??? Or have any suggesions.
Mostly venting my frustration, just managed the anxiety about getting a PICC Line and then found out its not happening; at least not for now!!
Thank you for your consideration, best, p.
Posts: 119 | From New York New York | Registered: May 2010
| IP: Logged |
kidsgotlyme
Frequent Contributor (1K+ posts)
Member # 23691
posted
I'm so sorry Piper. Hopefully someone will come along that can help you.
You should be able to go through an appeals process.
-------------------- symptoms since 1993 that I can remember. 9/2018 diagnosed with Borellia, Babesia Duncani, and Bartonella Hensalae thru DNA Connections. Posts: 1470 | From Tennessee | Registered: Dec 2009
| IP: Logged |
sammy
Frequent Contributor (5K+ posts)
Member # 13952
posted
I tried appealing (with doctor's letters and supporting info) for 18mo. I got a lawyer to help with the last 2 appeals. And my local congressman submitted letters on my behalf. It was still denied. Final appeal was a review done by my state insurance board.
I don't want you to be discouraged by this just know that you may have a very long frustrating road ahead of you. Or you may win with your first appeal.
So don't let them get off easy, you've got to try to fight for your coverage.
Good luck!
Posts: 5237 | From here | Registered: Nov 2007
| IP: Logged |
posted
ps. I should add that Health Net is being bought by United Health and the "roll-over" is either mid December or January...
Most likely if the doctor loses the appeal and I take it on it the will take longer...and by then Health Net will be out of business.
Not sure which insurance company my workplace will go with and my "new" insurance will not start until January.
Rumor is that my workplace is going with United Health (I hear they are worse than Health Net with aproving Lyme treatment??) and my LLMD will not take that insurance...
May have to wait until then and try with which ever new insurance company if offered.
Thank you for your reply's! best, p.
Posts: 119 | From New York New York | Registered: May 2010
| IP: Logged |
posted
You have the right to request copies of all documents used in denying your claim. I would request copies. Also ask for copies of the lyme treatment guidelines they are basing thier decision on.
They may be reluctant to provide the documents but pretty sure you have a legal right to this info -- put your request in writing and be sure to keep a copy and document all phone calls and letters to the insurance company. You need to create a paper trail.
Not saying this will change any decisions -- but to fight them you have to work around the system as best you can.
Also, one other possibility would be to ask for IV for babesia or bartonella rather than for lyme. Each illness will have its own set of treatment guidelines.
Hubby recently learned that Anthem BCBS actually considers babesia to be a life threatening illness -- so if you have positive tests for that coinfection that might be an easier fight.
Bea Seibert
Posts: 7306 | From Martinsville,VA,USA | Registered: Oct 2004
| IP: Logged |
Rumigirl
Frequent Contributor (1K+ posts)
Member # 15091
posted
What Bea is referring to is that you need to write and ask for an ERISA request, asking for ALL documents used in deciding your
request and the guidelines used to deny your request. ASk for the proper address to send it to. It's quite enlightening when you get the papers! That way you know how to combat their denial.
Also, get CALDA's insurance issue, it has tons of info.
My experience is that they don't read a word of what you sent though! But you have to fight it.
Also, the CDC says on it's website that their guidelines are NOT to be used for diagnosis. Copy that from the website and include it in your appeal.
Posts: 3771 | From around | Registered: Mar 2008
| IP: Logged |
Rumigirl
Frequent Contributor (1K+ posts)
Member # 15091
posted
Also, make complaints simultaneously to your state insurance board and the state AG, sending copies to the insurance co.
And get a lawyer (could be a friend doing a favor) to write a letter for you on their letterhead saying that you/he/she will hold the insurance company legally responsible for the negative health results of their denial of coverage.
Posts: 3771 | From around | Registered: Mar 2008
| IP: Logged |
The Lyme Disease Network is a non-profit organization funded by individual donations. If you would like to support the Network and the LymeNet system of Web services, please send your donations to:
The
Lyme Disease Network of New Jersey 907 Pebble Creek Court,
Pennington,
NJ08534USA http://www.lymenet.org/
UBBFriend: Email this page to someone!
Printer-friendly view of this topic