In your letter, you stated that the testing was medically necessary and would like Aetna to reconsider (Igenex testing):
Based upon our review of the information described, we are upholding the previous decision to deny benefits for the testing of Lyme Disease.
A Medical Director, who was not involved in the original denial has reviewed your appeal and determined that the diagnostic testing for Lyme disease was not medically necessary!
It goes on to say testing is covered, when clinically indicated, for evaluation of patients with CFS who have been in ENDEMIC AREAS!
In this case, there is no specific clinical information and the patient's address is Georgia. --------------------------------------------- The Igenex testing even shows I HAVE lyme disease so why would they say the testing isn't necessary? I was even CDC positive!
Its not even the money I'm after - its the princple of the thing. (Exhaling slowly.......)
posted
How about educating them with something called science.
Read my post about lyme diseease in the south. Two medical abstracts concerning your area. Also, there is a lyme like diesease well known to exist in the south, it is indeed medically needed to test for Lyme so that one can distinguish between STARI or Master's Disease, and Borrelia Burgdorferri Lyme Disease.
Send them the info, unless of coure you really don't care all that much, in which case, just get yourself healthy.
Posts: 559 | From Cary, NC | Registered: May 2006
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posted
Out of curiosity...are there people who have actually gotten insurance to cover the Igenex test?? I could not even get Blue Cross/Blue Shield to cover my routine doctor visits with dignosis code for lyme, never mind my Igenex test. That was a non-starter. I went through months and months of appealing, submitting records, re-submitting records (lost), submitting to different offices.....not a cent of anything lyme-related was EVER covered by them.
I no longer have BC/BS.
Posts: 393 | From Washington, DC | Registered: Jun 2005
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Was this an out-of-network LLMD that you will trying to get covered? I haven't had problems yet (cross my fingers) but I do have some out-of-network coverage.
Shelly
Also, when we had BC/BS, I submitted my Igenex bills just for the heck of it. For some reason, they paid all but $10!! Go figure!! They also paid all of MDL's testing. But we now have a local company, so we'll see what happens.
Posts: 292 | From UT | Registered: Aug 2001
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posted
My doc is out-of-network, so only a percentage of doc visits were covered (70% I think)...UNTIL the ICD code for lyme showed up on my bill. Then they of course didn't reject anything outright (then I would have cause to complain!), but sent me through this ridiculous hazing process of submit, resubmit, send to another office in another city, requested copies of ALL of my medical records for review. I got so fed up with it all I just got a different policy.
Different states have different BC/BS, so hopefully yours is less obstructionist! Sounds like you are having luck so far!
Posts: 393 | From Washington, DC | Registered: Jun 2005
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posted
When all else fails file a complaint with the state insurance commissioner -- hubby did this and got an employee at the insurance company fired. The insurance company is required by law to respond to complaints based on policies and procedures.
Be sure to document everything -- dates of phone calls made and who you spoke with etc and copies of all written correspondence.
Every state has an insurance commissioner.
Bea Seibert
Posts: 7306 | From Martinsville,VA,USA | Registered: Oct 2004
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cantgiveupyet
Frequent Contributor (1K+ posts)
Member # 8165
posted
WOW, I have Aetna and they paid for mine...well partial. I have a deductable for labs and this was last Nov...so by the time i got to my LLMD i met the deductable.
they paid about half of it.
I live in PA however, so maybe that was the difference...im not sure.
Are you being denied because you had another diagnosis of CFIDS before the lyme?
Hang in there and keep fighting.
-------------------- "Say it straight simple and with a smile."
"Thus the task is, not so much to see what no one has seen yet, But to think what nobody has thought yet, About what everybody sees."
-Schopenhauer
pos babs, bart, igenex WB igm/igg Posts: 3156 | From Lyme limbo | Registered: Oct 2005
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posted
I would look at your plan's benefits booklet for your plan's complaint/grievance process. You can get this if you don't have it by calling Customer Service, their number should be located on your insurance ID card. Do you have an HMO product that penalizes for out of network care?
Many plans, especially if you have an HMO or managed care product, have a tiered complaint and grievance process. Just because you were turned down once, you may be able to appeal that decision again to the insurance company, or as suggested, appeal to the state insurance commission.
You may want to check Aetna's medical policy website. Their lyme policy was just updated 6/2/06. Should you appeal the decision again, you may want to attach and highlight this policy.
Posts: 23 | From Camp Hill. PA | Registered: Dec 2005
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posted
Thanks 3 limes, I'll do that. You would think if they updated their lyme policy, a copy of it would've been given to the "Medical Director" who denied my claim but maybe not.
I'm beginning to think they didn't even look at the Igenex test to see that it was positive - they just denied the test based on the fact that Georgia "has no lyme."
posted
I'm sure there is documentation somewhere that Lyme exists in Georgia. What about traveling? Don't they think you could have traveled to another Lyme-endemic area?? [duh!]
I thought Aetna paid for my test also....but that was 6 yrs ago and my memory isn't so grand!!
-------------------- --Lymetutu-- Opinions, not medical advice! Posts: 96239 | From Texas | Registered: Feb 2001
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bettyg
Unregistered
posted
Are you on medicare? Been approved for SSDI so medicare is no. 1 payee?
I won my SSDI, on medicare, & MEDICARE PAID all my recent IGENEX bill of $ 905.00.
When I tested for western blot IGM/IGG; my SSDI had NOT been approved at that time. Calif. BCBS paid $43.00 since I was OUT OF NETWORK.
If IGX would have been on IOWA'S approved list of labs, they would have paid 80%.
posted
Is the Aetna plan you have a managed care plan (HMO)? If so Aetna will not cover the labs as you have to have them drawn at a capitated lab (either Quest or Labcorp).
posted
Bettyg - no I'm not on Medicare but thanks for that information.
Timaca - I'll look for your post, thanks
Blur - ha-ha, yes, they've paid for most of my Quest blood work which was in the thousands - on my first visit at the Fibro and Fatigue Center they took 23 vials of blood. They are very thorough.
SForsgren
Frequent Contributor (1K+ posts)
Member # 7686
posted
Or contact an attorney. Aetna is one of the worst there is...period....
-------------------- Be well, Scott Posts: 4617 | From San Jose, CA | Registered: Jul 2005
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Truthfinder
Frequent Contributor (1K+ posts)
Member # 8512
posted
I just had to drag this back up and comment.....
Evidence of Lyme in Georgia? If that is Aetna's excuse for non-coverage of a positive test (that blows me away, too), then I think they basically shot themselves in the foot.
Even the CDC acknowledges Lyme in Georgia - just look at the CDC map, for crying out loud.
Boy, I sure would complain to your state Insurance Commissioner, at the very least.
Good luck - let us know what happens.
Tracy
-------------------- Tracy .... Prayers for the Lyme Community - every day at 6 p.m. Pacific Time and 9 p.m. Eastern Time � just take a few moments to say a prayer wherever you are�. Posts: 2966 | From Colorado | Registered: Dec 2005
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