You might need to see a LLMD and start treatment before relying on any MA. Let us know how it goes. Neil
PS: HealthNet, a Medicare Advantage HMO (MA), must offer all that Medicare does - which does not exclude antibiotics for infections.
So their policy will not exclude Lyme disease treatments.
That said, my HealthNet PCP says the Plan will not allow him to prescribe for Lyme. THAT duty belonged to two Infectious Disease (IDSA) Drs., one in a local hospital.
Hence IDSA guidelines led to sufficient "doubt" to rule out my Lyme diasease as my Western Blot serology was -neg. and the ID Drs. believe even late stage Lyme is cured with short term antibiotics. And of course no MA ID Dr. here in Tucson believes in refractory Lyme disease.
I enrolled in HealthNet after completing IV antibiotics. United and HealthNet pay/paid for oral abx prescribed by ontside doctors. For that I am grateful.
But local MAs wll NOT approve IV abx for LD.
I fought that 3 years against United and won but the United Healthcare policy was not MA.
Except for cancer treatments at oncologist's office I don't think MAs offer outpatient (IV) treatments at ambulatory clinics. They prefer to administer routine, non Cancer IV treatments at hospitals. And it appears that Hospitals are paid by Medicare per the Diagnosis Related Group (DRG) process.
The DRG is the diagnosis times the expected time to treat in hospital. Which equals the payment to the hospital.
If you need more time to get well, they lose $$.
If you get discharged early, they keep the difference.
Can someone help me find the DRG list? The best I have been able to learn is that DRGs are found in a special disc for sale ~$600.
DRGs do not appear to be public information!
No hospital can be expected to offer routine Lyme disease treatment, inpatient or outpatient, unless there is a DRG.
The Kotler case in Calif decided that Lyme D treatments are not a medical emergency.
A search of "IDSA" + "Lyme" on HHS.gov gets loads of links all leading to the IDSA Lyme Disease diagnosis and treatment Guidelines.
These enjoy such HHS popularily that it is all too evident that HHS officialdom does not have a DRG for refractory Lyme disease.
So I bet 10 cents there is no DRG paying for IV antibiotics for Lyme D under Medicare, which is managed by the HHS.
No reg or law excludes IV antibiotics for Lyme disease but getting them through an MA is not so easy. At least not here in the Old Pueblo.
Can someone help find the DRG for late stage or refractory Lyme disease?!
-------------------- Neil Posts: 697 | From Tucson, AZ USA | Registered: Apr 2002
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I am in Healthnet Orange in Masachusetts. My coverage for Zithromax is limited to five or six days(pills). No such limit for the older tetra/doxy class which are availble as generics. You and your doctor might be able to get an override on the Zith limit, I don't know.
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There is a process for appealing denial of medication coverage. Ask your plan for details. If your doctor is willing to go to bat for you and supply them with support for using a specific drug over others, then they should cover you.
-------------------- Suzanne Shaps STAND UP FOR LYME Texas (www.standupforlyme.org) (Please email all correspondence related to protecting Texas LLMDs to [email protected] with copy to [email protected]) Posts: 977 | From Austin, TX, USA | Registered: May 2004
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