posted
I have a clinical diagnosis of Babesia Duncani. My Igenix test IGG was 1:80. The Igenix Test says over 1:640 is considered positive.
Obviously that is not respected by BC Blue Shield. They denied coverage for my RX. I faxed them a copy of my Babesia Duncani test result. Again, they denied. They say they want a blood smear test or FISH test?? Can they require that? I mean dictate what type of test??
What is a smear test??
I thought lyme and co-infections are a clinical diagnosis so isn't my LLMD's diagnosis counting for anything?
I am new to all this with diagnosis and treatmen. Just diagnosed in Aug08. But, not new to this chronic illness; misdiagnosed for 15 yrs.
So, what should I do next? Can anyone please help me. I am in tears over this so I really appreciate any help, thank you.
[ 15. January 2009, 10:47 PM: Message edited by: jam338 ]
Posts: 495 | From SF Bay area, CA | Registered: Dec 2007
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posted
Lymestop, thanks for your reply...did you have to submit test results to them??
Posts: 495 | From SF Bay area, CA | Registered: Dec 2007
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Amanda
Frequent Contributor (1K+ posts)
Member # 14107
posted
Hi,
You could ask you doctor to run the test, send the docs office a copy of the insurances response.
I would also send BCBS a more formal response. The California lyme disease associate has form letters you can download, and they were written by someone with legal experience in insurance denials.
-------------------- "few things are harder to put up with than the annoyance of a good example" - Mark Twain Posts: 1008 | From US | Registered: Dec 2007
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posted
I'm so sorry you're continuing to battle Blue Shield over your meds. Such unnecessary stress!
I suspect your insurance company is insisting on additional testing because your Babesia diagnosis is based on IgG antibodies, which "mainstream" medicine considers to be only a past infection.
Then 2nd page discusses "Laboratory Diagnosis". There are 3 types of testing described. Here is the discussion on antibody testing...I'm assuming it's implied that the titers referred to are IgM because there is no mention of IgG.
My doctor got upset because they told him the same thing. I had a FISH test, which IS a smear, and they still denied it. He called, sent them info, and still.....they denied it.
I appealed, and they half-conceded that I had a blood smear, but came back and told me that I had to test positive for babesia MICROTI to be eligible for treatment.
I had a very frustrating, kafka-esque conversation with the woman handling my claim trying to explain to her the concept of 'strain's. She did NOT get it, told me that she didn't have a degree in medicine. I mean, neither do I. I explained in layman's terms. Still, no dice.
The second part of their denial for their appeal was to say that even if I DID need treatment for babesia, 7 days worth of mepron cures it.
They've denied virtually everything, I've appealed things over and over (one thing, before my lyme diagnosis, I appealed all the way to the state, with 3 letters of support from doctors, and still got denied.
I have the best coverage they offered. Since my illness began, I have spent over $30,000 out of pocket. And I only RECENTLY got the lyme/babesia diagnosis.
I'm sorry to tell you a not-positive story, but they're really unreal. You can keep appealing, and I would encourage you to do so, but I had bad experiences.
Posts: 322 | From Venice, CA | Registered: Sep 2008
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posted
don't say that. I just changed to Blue Cross this year. I have a $2400 deductible then they should pay 80%. I still have some Mepron from my refill last year. Guess I'll find out soon.
Posts: 975 | From California | Registered: Apr 2007
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bettyg
Unregistered
posted
lymestop,
so is this is what you are saying:
BCBS IS NO. 1 Payee;
medicare is 2nd payee vs. being the other way around??
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posted
I think BCBS varies as to where you live. I had a few problems at the beginning, but so far they have paid for everything, minus my copay. I was on mepron for several months.
The biggest problem was the bicillin shots, but they did end up paying for them.
I have had no success with antibiotics, so I was just given the choice of Cowden or IV rocephin. I opted for the Cowden b/c I know BCBS will not pay for the rocephin. There is no way I can afford to pay myself.
Keep appealing, sooner or later they will get sick of it. Good luck.
Posts: 847 | From upstateNY | Registered: Dec 2007
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richedie
Frequent Contributor (1K+ posts)
Member # 14689
posted
Try to get a FISH test. I got this from IGENEX and it was positive, I had no issues.
-------------------- Mepron/Zith/Ceftin Doxy/Biaxin/Flagyl pulse. Artemisinin with Doxy/Biaxin. Period of Levaquin and Ceftin. Then Levaquin, Bactrim and Biaxin. Bactrim/Augmentin/Rifampin. Mepron/Biaxin/Artemisinin/Cat's Claw Rifampin/Bactrim/Alinia Plaquenil/Biaxin Posts: 1949 | From Pennsylvania | Registered: Feb 2008
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posted
I know this thread is from a while back but just wanted to post my experience as it relates to this topic for those in similar situations. I also have Blue Shield (CA) and was rejected for Babesia duncani mepron coverage after requesting a prior authorization. I had a positive IGG and not an IGM. They said they needed a positive FISH for Babesia microti. I submitted a FISH which was positive for Babesia duncani. It was rejected due to not being a pathogenic species. I then filed a grievance and printed out document showing pathogenicity of Babesia duncani from CDC website, (highlighted important parts) and from the NIH as well. A month later, I just received word that my request for Mepron coverage was approved. Hoping this helps.
-------------------- -Starburst Posts: 1 | From san francisco | Registered: Jan 2017
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posted
Keeping this up for others that may need it. I had trouble with coverage as well. United was perfectly awful. The steps offered here I'd repeat if I was in these shoes again. Hang in there!
Posts: 859 | From Southeast | Registered: Mar 2011
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