posted
Does anyone have any ideas on how to overturn an insurance denial for treatment? I am at my wit's end!
I have a physicain diagnosed EM rash with pictures, 3 positive PCR's, a positive ELISA and a negative Western Blot(only band 41 was present).
Their reason for denial is "no evidence of lyme disease"! This infuriates me! I have filed an appeal and they have 60 days to respond.....which will be up next week.
They said since my tests don't meet CDC standards and my last PCR was neagative, I do not have lyme disease. They are so clueless! I have sent them all the info I could copy, but I doubt they even read it.
Any suggestions on what to do next? I haven't had treatment in over a year and a half now. In the meantime, I have this raging rash on my neck and the back of my head.
Posts: 195 | From NJ | Registered: Nov 2003
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SForsgren
Frequent Contributor (1K+ posts)
Member # 7686
posted
What is the dispute over the positive PCRs? Those are pretty clear indication. Did they have any logic for that? Also do they understand that the CDC even states that Lyme is a clinical diagnosis. What "evidence" are they looking for? At some point, an attorney might be a good option.... I will be interested in seeing what others recommend on this critically important topic.
-------------------- Be well, Scott Posts: 4617 | From San Jose, CA | Registered: Jul 2005
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timaca
Frequent Contributor (1K+ posts)
Member # 6911
posted
You might check out the back issue of Lyme Times...it is an insurance issue and has lots of good info. I used (and am still using it) for my insurance appeals.
I think you can find either the issue or how to purchase it at www.lymetimes.org.
You might want to consider starting treatment while you fight your insurance company. Your health is important.
I did that, and they eventually (at least so far) have covered my treatment.
Good luck....
Posts: 2872 | From above 7,000 ft in a pine forest | Registered: Feb 2005
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posted
Thanks to all for your ideas and suggestions. I will continue to pursue the insurance company.....they charge enough for the premiums! I'm not letting them off the hook that easy.
I have sent them pictures of the rash and lots of documentation concerning the CDC's stand on lyme being a clinical diagnosis.
For some reason they want a positive western blot and nothing else for a diagnosis of lyme! I guess they do not read the CDC guidelines even though they claim to be following them.
My next step may be to approach the insurance commission or the attorney general, but unfortunately my insurance plan is through a self insured company. All this means is that they are not governed by state regulations. Guess that means another dead end.
Thanks again for your input.....you all always have great things to say!
Posts: 195 | From NJ | Registered: Nov 2003
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posted
By the way......I have only been tested for coinfections 1x (a year ago) and those results were negative.
Posts: 195 | From NJ | Registered: Nov 2003
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posted
I think I'm right on this---------if the insurance is provided by employer who is self-insured, you can file a "nice" appeal directly to the employer???
Attach ILADS Guidelines about the diagnostic signs of Lyme ------the rash. It's the pathognomonic (distinctively characteristic of a
particular disease) sign of a borrelia infection and is used for diagnostic purposes. It trumps the Western Blot test-------or rather it's suppose to.
Years ago we did that with a company my husband worked for & they had the authority to override the insurance company's vetoes.
Also, the FDA has a page somewhere that states LD is a clinical diagnosis & admonishes physicians to abide by this guideline.
Would your insurance company believe Igenex lab's results for a Western Blot IgM & IgG or will they only use their own labs which are set up for negative results?
My first Igenex western blot was negative, but after taking 12 days of Zithromax & then testing, it was highly positive.
Maybe you could go to an osteopath who are usually more open minded & explain the situation. They might prescribe some Zithromax for you for testing purposes only.
An alternative doctor might also prescribe Zith as above.
Just throwing some things out there for you. Not giving up is the key.
Best of luck, Jan
Posts: 222 | From Texas | Registered: Jan 2005
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posted
Thanks Jan, I did some checking, and you are correct. I can appeal directly to the employer and they have the right to overrule the insurance company if they choose!
Thanks so much for that insight. They certainly don't let on that you can do this! I now have some new battling to do!
Posts: 195 | From NJ | Registered: Nov 2003
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i suggest getting the book(s) and use as a template, modified to lyme and other TBDs.
their motto is "...an early death is a cheap death."
tape record all phone discussions. find out your state's law regarding this. often, a given insurance co. rep. your speaking with is in a state that has a law against recording someone without their knowledge; other states have a law where only on party can have knowledge of the recording and that can be you.
i just say something like "...due to neurocognitive problems i am recording this... "
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