posted
I'm needing information that show my tests were not "excessive and repetitive" as the insurance review states. (By the way, they charged (and paid) my account for this review-is that normal?) Any ideas on what to give them when I appeal so they will pay?
I contacted the labs and some are sending me more information.
IGX- Lyme screening- will pay for 2/12 tests (tests confirmed lyme)
Redlab-Chronic infection screen panel- denied all (tests showed no EBV or other viral infections)
Spectracell-comprehensive profile- most denied (tests confirmed vit.& mineral deficiencies)
This adds up to over $4000.00! They haven't ever denied services to me before being tested for Lyme. I have had many tests ran in the last two years at Mayo and they were as expensive, but not the same tests. Seems if my LLMD orders them, they are questioned. What can I do?
map1131
Frequent Contributor (5K+ posts)
Member # 2022
posted
Oh boy! You've got some major paperwork to do, in order to fight these guys. Is the LLMD out of your service area and state? Is this you first visit with LLMD?
My insurance company for my first two LLMD tests were right on paying and no problems. At that time I needed pre-approval/referral.
Everything was fine until the third visit to LLMD and my insurance company said we aren't paying for you to go to this doctor anymore. I was traveling 8 hrs one way and spending night in hotel.
I appealed my insurance company. They called every ID doctor in my city and asked them if they treated lyme disease. They all said yes. So my insurance company told me to go to one of them.
This was after I'd been on abx for two years and treated by my primary doc. Him and I weren't getting anywhere, so I was of the opinion that I needed to see a lyme literate doctor.
I wouldn't go to a ID doctor in this city then if insurance paid me for my time and effort to go and paid every single penny of the bill.
I hope you get some ideas on how to proceed. Long lenghty detailed letters of appeal process didn't help me. I'm sorry, I wish I could help.
Pam
-------------------- "Never, never, never, never, never give up" Winston Churchill Posts: 6478 | From Louisville, Ky | Registered: Jan 2002
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TerryK
Frequent Contributor (5K+ posts)
Member # 8552
posted
wantabe, Sorry you are having trouble. Check out this page and see if you can get some help here. They say that most insurance pays. They will file an appeal for you and do some other things that might help. http://www.spectracell.com/started/add_insu_info.htm
I'd check each labs website to see if you can get any help there.
TerryK- I hadn't been to Spectracell's web site-thanks! I did use the prepay and they said on the phone that would cover the amount not paid. Good for me-not for them.
Do I contact Blumenthal-Connecticut even though I'm out of state?
Tincup- IGX tests were:
Western Blot-IGM, Western Blot-IGG Babesia IGG antibody, Babesia IGM antibody Anaplasma Phag IGM, Anaplasma Phag IGG HME antibody-IGG, HME antibody IGM Babesia FISH Lyme IFA A/M/G
They paid for the first and last test listed.
Are these "excessive and repetitive"? IGX sent specific details to the insurance co. explaining the tests and procedures used.
My general experience with insurance companies is this: Most clerks don't know what they're doing because they're too young to know.
They don't know medical terms, illness names and do their job with blinders on, because they are young. Then a few or several months later they quit and another fresh, green, young clerk takes their place.
Only you can decide how to proceed, but I'll offer one consideration, for what it's worth. OK?
Call your insurance's complaints department (grievances.) Say the LLMD was pre-approved.
You got this bill from outer space (or whatever) and you want an explanation, because you fully expected your insurance would pay for it.
Does your state have an appeals process through your states insurance board?
If so, maybe call, talk to a person there for a long time and get their name. Then call back the complaints person at your insurance company and say, "I just called the State Insurance Board (Commission?) and I talked AT LENGTH with ______________."
Does that open the door for you?
Insurance companies really, really, really don't want the state insurance appeals board to be involved in any of their customers complaints.
They don't want you to know that it exists. Insurance companies are often rated by state insurance boards just by the number of complaints by phone, plus appeals.
That's a tool. Strategy!
Maybe you can get this taken care of in a snap.
Then again, maybe not.
Or call the person who signed the letter. (Did anyone sign it?) Ask what it is that they need to dot their "i's" and cross their "t's," because you are just shocked!
You are not a lawyer! (Well, maybe you are!) It is not rational that you can be presented with something like that and that you will then know what to do. Tell 'em that. Put it on them to tell you what they need, from you.
That's fair. That's rational.
Or, after filing a formal complaint (appeal) with your insurance company (telling them on the phone that you will take this to the state outside appeals process if you have to,) if they still won't pay, then actually go to an outside appeal with your state insurance board.
I'm really hoping you have a state insurance board (commission?) with an appeals process. This takes it out of the control of the insurance company because it's an outside appeals process.
That's the essence of this tool.
Most people don't know about this and so most don't use it!
Good luck. It's a pain, I know.
Gee, I hope they don't use this action as an excuse to dump you. I'm just stating that ... in case. It's something to consider, as well.
This bull befuddles we Lymies: stress, stress, stress! It is injurious to a Lymie when they pull this bull.
daise
P.S. Does your local Lyme support group know of experiences like this with that insurance company? Maybe someone already knows the path to get this fixed. That's be great, because, why re-invent the wheel?
I would call the insurance agent and NICELY ask what the problem is? Sometimes they just don't know anything about Lyme and the need for co-infection tests.
Tell him/her the tick borne disease coinfection tests go together with the Lyme test like peanut butter goes with jelly. Really.. you can say that.
Tell them you will send any documentation they may need... and do it IMMEDIATELY. Ask for their email so you can forward to them ASAP. They MUST have documentation.. the more the better.. to approve the testing.
What I have posted below should do it.
It shows ticks are in Iowa.. and what diseases they carry. Officially documented.
DO NOT SEND THEM TO LYMENET!!!!
Just in case you would have.
I would also be sure to print out the first document at the link I provided below. It is about ticks and tbd's in Iowa.. from an offical source. They should be impressed with it.. but do copy and paste the other quotes and medical abstracts too.
Hope that helps.
"The LDSP has documented infected blacklegged ticks in 17 counties in Iowa (Fig. 3). This species of tick also can transmit bacteria (Anaplasma phagocytophilum) that cause human granulocytic ehrlichiosis (HGE), equine ehrlichiosis, tick-borne fever, and pasture fever. It can transmit viruses, such as deer tick virus and the virus that causes Powassan encephalitis."
"American dog ticks are carriers of the bacteria that cause Rocky Mountain spotted fever (Rickettsia rickettsii). This disease is rarely seen in Iowa -- only 51 cases have been reported since 1990. These ticks also can transmit the bacteria that cause rabbit fever (Francisella tularensis). In addition, they may cause tick paralysis, an uncommon but potentially fatal malady in which a female tick that has been attached for days paralyzes its host, though the paralysis disappears within a few hours of the tick's removal."
"Lone star ticks can transmit the bacteria that cause rabbit fever (Francisella tularensis), canine and human granulocytic ehrlichiosis (Ehrlichia ewingii), and human monocytic ehrlichiosis (E. chaffeensis)."
"Other signs and symptoms of Lyme disease include arthritis (especially in the knees), facial paralysis, neurological and cardiac problems, general malaise, and fatigue. Successful treatment for Lyme disease requires antibiotic therapy."
University of Iowa Health Science Relations and Nelson Moyer, PhD Adjunct Professor of Occupational & Environmental Health First Published: November 2000 Peer Review Status: Internally Peer Reviewed
"Ticks may carry organisms that can cause one of several rare diseases, with Lyme disease, ehrlichiosis and Rocky Mountain Spotted Fever being the most common in Iowa. Tick-borne diseases typically begin with a low-grade fever, headache, malaise, and possibly a rash. Left untreated, the symptoms may progress to serious and even life-threatening conditions."
"The three most common tick species in Iowa have different geographical ranges within the state and are most active at different times of the year. The dog tick (also known as the wood tick), which can transmit Rocky Mountain spotted fever, is found statewide, usually from April through July."
The Lone Star tick, which can transmit ehrlichiosis, inhabits southern counties along the Missouri border. It is most common in the late summer and early fall.
The deer tick, which can transmit Lyme disease, is found in northeastern Iowa and in counties bordering the Mississippi River. The deer tick actually has two distinct seasons: early spring-June and September-October."
By law, there are 5 tick-borne diseases that are required to be reported by physicians and labs to the Iowa Dept. of Public Health. These include Lyme disease, Ehrlichiosis, Tularemia, Rocky Mountain Spotted Fever, and Q-fever. Unfortunately cases are diagnosed and treated and not reported to the public health departments, leading people to believe tick illnesses are not a public health issue.
In 2005, Iowa ranked 16th in the U.S. for the incidence rate of Lyme disease cases and 15th for the actual numbers of cases. (Source: U.S. CDC)
The University Hygienic Lab in Iowa City reported in 1999 that Lyme disease is underreported and under-recognized by physicians in Iowa.
Vector Borne Zoonotic Dis. 2006 Fall;6(3):275-82. Links Serosurveillance for Anaplasma phagocytophilum antibodies in white-tailed deer (Odocoileus virginianus) in Iowa, USA.Rainwater KK, Ijdo J, Capuano A, Gilchrist MJ, Gill JS. University of Iowa Hygienic Laboratory, Iowa City, Iowa 52242, USA.
Cases of human granulocytic anaplasmosis have increased in number and are being identified in new geographic areas since its discovery in 1994. White-tailed deer (WTD) become infected with the causative agent, Anaplasma phagocytophilum, and serve as natural sentinels for this organism. In order to determine if A. phagocytophilum is present in the state of Iowa, sera collected from 628 WTD in 2004 from 13 sites and from 282 WTD in 1999 from a single, common site were tested by enzyme-linked immunosorbent assay and Western immunoblotting. A seroprevalence of 9.1% was found among the 2004 samples, and there was no change in seropositivity rates from 1999 to 2004 at the single, common site. As A. phagocytophilum is another tick-borne human pathogen to be identified in the state of Iowa, this study has important implications for health care providers.
PMID: 16989567 [PubMed - indexed for MEDLINE]
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Vector Borne Zoonotic Dis. 2005 Fall;5(3):219-26. Links Geographic distribution of ticks (Acari: Ixodidae) in Iowa with emphasis on Ixodes scapularis and their infection with Borrelia burgdorferi.Lingren M, Rowley WA, Thompson C, Gilchrist M. Department of Entomology, Iowa State University, Ames, Iowa 50011-3222, USA.
In Iowa, public concern regarding Lyme disease has increased markedly over the last decade. In response to these concerns, a statewide surveillance program was initiated in 1990 based on ticks received by the Department of Entomology at Iowa State University. Ticks were received from health care professionals, state government agencies, and the general public. A total of 5,343 ticks from all 99 Iowa counties were identified during the 12 years of this study. Dermacentor variabilis was the most numerous species, followed by Amblyomma americanum, and Ixodes scapularis. Dermacentor variabilis were distributed statewide, but A. americanum came primarily from southern Iowa counties. Prior to 1996, most I. scapularis came from counties along the Mississippi River. In the last 5 years, I. scapularis have been received from several counties in central and western Iowa and there is molecular evidence of infection with Borrelia burgdorferi in a substantial percentage of ticks. All I. scapularis were tested for the presence of B. burgdorferi. During the 12 years of this study, the presence of B. burgdorferi in I. scapularis varied from a low of zero percent in 1991-1995 to 18% in 1996. On average, fewer than 10% of all ticks examined per year were I. scapularis. In the 2000 tick season, the number of I. scapularis per year increased to 22% of submissions. This species further increased to 36.6% of ticks received in 2002.
PMID: 16187889 [PubMed - indexed for MEDLINE]
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J Med Entomol. 2005 May;42(3):473-80.Links Detection of Rickettsia, Borrelia, and Bartonella in Carios kelleyi (Acari: Argasidae).Loftis AD, Gill JS, Schriefer ME, Levin ML, Eremeeva ME, Gilchrist MJ, Dasch GA. Viral and Rickettsial Zoonoses Branch, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA. [email protected]
Carios kelleyi (Colley & Kohls 1941), a tick associated with bats and bat habitats, has been reported to feed on humans, but there is little published data regarding the presence of vector-borne pathogens in these ticks. C. kelleyi nymphs and adults were collected from residential and community buildings in Jackson County, Iowa, and tested by polymerase chain reaction for Rickettsia, Borrelia, Bartonella, Coxiella, and Anaplasma. Rickettsia DNA was detected in 28 of 31 live ticks. Sequences of the 17-kDa and rOmpA genes suggest that this agent is a novel spotted fever group Rickettsia. Transstadial and transovarial transmission of this Rickettsia were demonstrated. The flagellin gene of a Borrelia, closely related to B. turicatae, was detected in one of 31 live ticks. The 16S-23S intergenic spacer region of Bartonella henselae also was detected in one of 31 live ticks. Coxiella or A. phagocytophilum DNA were not detected in these ticks.
PMID: 15962801 [PubMed - indexed for MEDLINE]
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J Clin Microbiol. 1997 Jun;35(6):1465-8. Links Prevalence of granulocytic Ehrlichia infection among white-tailed deer in Wisconsin.Belongia EA, Reed KD, Mitchell PD, Kolbert CP, Persing DH, Gill JS, Kazmierczak JJ. Marshfield Clinic and Marshfield Medical Research Foundation, Wisconsin 54449, USA. [email protected]
Human granulocytic ehrlichiosis (HGE) is caused by an agent that is nearly indistinguishable from the veterinary pathogens Ehrlichia equi and Ehrlichia phagocytophila. The deer tick, Ixodes scapularis, is a vector of the HGE agent, and the white-tailed deer is the primary host for adult Ixodes ticks. We assessed the distribution of granulocytic Ehrlichia infection among deer living within (Wisconsin) and outside (western and southern Iowa) the geographic range of L. scapularis. Whole-blood samples were tested for HGE 16S ribosomal DNA (rDNA) by PCR, and E. equi antibody was detected by indirect immunofluorescence assay (IFA). Antibody titers of > or = 1:64 were defined as positive, and all positive samples were retested with a second lot of substrate antigen. E. equi antibody was present in 14 (8%) of 187 Wisconsin deer and 0 of 60 Iowa specimens (rate ratio undefined; P = 0.025). An additional 30 serum samples from Wisconsin deer were excluded because IFA results were discrepant between substrate lots. The reciprocal antibody titers ranged from 64 to 512 (geometric mean, 141) for positive samples. PCR results were positive for 27 (15%) of 181 Wisconsin deer. The prevalence of infection in northwestern Wisconsin deer was not significantly different from that in central Wisconsin deer, as determined by IFA and PCR. In two samples that were sequenced, the 16S rDNA was nearly identical to that of the granulocytic Ehrlichia species but distinct from that of Anaplasma marginale. The DNA sequences of the samples differed from the published sequences for E. equi, E. phagocytophila, and the HGE agent by 1 or 2 nucleotides (> or = 99.1% homology) at phylogenetically informative sites. Granulocytic Ehrlichia organisms in deer are widely distributed within the geographic range of L. scapularis in Wisconsin. Deer may serve as useful sentinels for areas where HGE transmission to humans may occur.
PMID: 9163463 [PubMed - indexed for MEDLINE]
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J Wildl Dis. 1996 Jul;32(3):444-52. Links The role of deer as a possible reservoir host of potosi virus, a newly recognized arbovirus in the United States.McLean RG, Kirk LJ, Shriner RB, Cook PD, Myers EE, Gill JS, Campos EG. Division of Vector-Borne Infectious Diseases, Centers for Disease Control and Prevention, Fort Collinis, Colorado 80522, USA.
Potosi (POT) virus (Bunyaviridae) was isolated from Aedes albopictus, an introduced Asian mosquito species, collected at a used tire yard in Potosi, Missouri (USA), in August and September, 1989. In September, 1990, small animals were trapped at the tire yard and six cattle were sampled at an adjacent farm; in November 1990 and 1991, blood samples were collected with filter paper strips from 364 hunter-killed, white-tailed deer (Odocoileus virginianus) in the region to determine the possible reservoir hosts of the virus. Deer specimens from Arkansas (n = 70), Colorado (n = 29), and Iowa (n = 763) (USA) were also analyzed. Specimens from 33 small vertebrates captured at the tire yard were negative for viruses. Only one eastern chipmunk (Tamias striatus) and none of six cattle had neutralizing (N) antibody against POT virus by the plaque-reduction serum neutralization test in Vero cell culture but 45 (25%) of 178 deer specimens in 1990 and 55 (30%) of 186 in 1991 were antibody positive. The 186 deer sera from 1991 were tested further and 29 (16%) were also N antibody positive to Cache Valley (CV) virus. From the 763 deer specimens tested from Iowa in 1993, 114 (15%) had N antibody to POT virus. Of 70 serum specimens from Arkansas deer in 1990, 33 (47%) had N antibody to POT and 15 (21%) to CV viruses; two (7%) of 29 CV negative serum specimens from Colorado deer in 1981 were serologically positive to POT virus. Three eastern chipmunks were experimentally inoculated with POT virus to determine their reservoir potential; none became viremic but all developed N antibody. Thus we propose that POT virus may be another virus regularly infecting wild deer populations but its impact on the health of these animals is unknown.
PMID: 8827670 [PubMed - indexed for MEDLINE]
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Iowa Med. 1991 May;81(5):215-7.Links Lyme disease: the picture in Iowa.Rowley W, Platt K, Novak M, Currier R. Iowa State University, Department of Entomology, Ames.
Lyme disease in Iowa increased sharply in 1989 and 1990, creating concern in Iowans who spend considerable time out-of-doors. The authors review the history of Lyme disease and its symptoms and present an update on the status of Lyme disease and its tick vector in Iowa.
PMID: 1869426 [PubMed - indexed for MEDLINE]
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Iowa Med. 1989 Jun;79(6):277-80.Links Fulminant refractory Lyme disease.Manning PG. Lyme Disease, which is carried by ticks, has not been widely reported in Iowa but does occur here. The author discusses a case which involved most of the classic landmarks of the various stages of the disease.
PMID: 2737847 [PubMed - indexed for MEDLINE]
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J Clin Microbiol. 1988 Dec;26(12):2632-6. Links Borrelia burgdorferi infection surrounding La Crosse, Wis.Callister SM, Agger WA, Schell RF, Ellingson JL. Microbiology Research Laboratory, Gundersen Medical Foundation, La Crosse, Wisconsin 54601.
This investigation defined the extent of Borrelia burgdorferi infection surrounding La Crosse, Wis. White-footed mice, Peromyscus leucopus or P. maniculatis, were captured from sites in Wisconsin, Minnesota, and Iowa and cultured for B. burgdorferi to define the local boundaries of the midwestern Lyme disease area. All foci of B. burgdorferi infection (N1, N2, N3, and N4) were located north of interstate highway 90 except focus S2, which was south of the highway near Fort McCoy, Wis. The interstate highway may have been a barrier to deer movement which slowed the southward dispersal of Ixodes dammini. B. burgdorferi was isolated from 12 (63%) of the mice captured from site N4, which was adjacent to the western border of Fort McCoy. Unexpectedly, no B. burgdorferi-infected mice were isolated at site N0, located north of interstate highway 90 and enclosed by areas in which B. burgdorferi infection is endemic. This site is surrounded by natural barriers which may have slowed the spread of I. dammini by deer. The Wisconsin area in which B. burgdorferi is endemic should now include the surrounding area north of interstate highway 90 west from Fort McCoy to the Mississippi River. Additional studies are needed to define the rapidity, limits, and means of I. dammini dispersal into southern Wisconsin.
Tincup
Honored Contributor (10K+ posts)
Member # 5829
posted
As for the other tests...
Truth is... I am too tired right now to research more, sorry.. but maybe someone else can assist you.
Do like I have and go to PubMed and type in Lyme thyroid.
READ all the abstracts to be SURE they are what you need.. then save them like I did these others to send in.
Do the same with vitamins and the rest of the tests... and try to ONLY use idiots abstracts for the references.. ducks and such... and NOT LLMD's stuff.
They can argue with our LLMD stuff.. but not when their own sources say it.
But first make the call. They may not need the other stuff if you overwhelm them with the TBD stuff first.
And be nice!!!
Wish I could do more but am running on empty right now. But if you need more help later.. give a holler.
posted
Tincup- You are my hero! You are amazing! You are...I could go on if it wasn't for this word block...
The information you gathered is great. I taught all day and then had parent/teacher conferences all night, but plan on sending this to insurance co. on Wednesday. How can they dispute all those facts? I'm sure you will send me a bill for this-um-I'll get my address to ya. Seriously, you may have saved me some big bills. I'll keep you updated.
Your information on where to search for more information is very helpful as well-sad that we have to go through this-glad that you have helped!
Thanks for the reminder to be nice- I'll kill them with kindness if I have to.
posted
Update on appeal process: Sent certified letter and 18 pages of documentation regarding the IGX labs. Thanks for all your research and ideas-it came in handy! Including part of the letter-let me know your thoughts. ------------------------------------------------
Notice of Appeal for claims: 00XXXXXXXXXXXXX-MM and 00XXXXXXXXXXXXXX-MM
Date of service: xx-xx-xx Provider: IGeneX INc Service Provided: Diagnostic Laboratory Testing
Date Explanation of Benefits received: February 28, 2008 Date appeal was mailed- US Post Office certified mail: March 7, 2008
Employee: XXXXXXXXX Group Name: XXXXXXXXX Patient: XXXXXXXXXX
Reason Code given for not paying charges: 24 Not Allowed by Plan
Covered charges stated in employee benefit booklet: Diagnostic X-Ray & Lab -100% after deductible
The tests that were performed on xx-xx-xx and sent to IGX were necessary to diagnose and start treatment on an active case of Lyme (b. Burgdorferi) and coinfections. Physical symptoms, examination, and documented history of medical problems were used to determine what tests were needed to be administered to diagnose and start treating my infections and deficiencies. After test results were examined by my doctor, treatment began and improvement in my debilitating physical state is beginning. Without these tests, I would still be undiagnosed and unable to begin my recovery. I would still be seeing specialist after specialist trying to find an answer.
I have included many researched and cited resources for you to review to help you understand why the tests were necessary. Lyme and coinfections are often undiagnosed or misdiagnosed when testing and clinical examinations are not performed. As stated in the ILADS Guidelines for Lyme Disease, ``...concurrent testing and treatment for coinfection is mandatory in Lyme disease patients.''
IGX included an explanation and description of their tests when this claim was originally filed. These show that their testing procedures are not excessive and repetitive. If you need more information from them, contact me.
Please let me know if you need more information to help you understand the complexities of Lyme and its coinfections. This has been a long journey for me trying to find why I was sick and what I could do about it. (Please check my past records to see all the specialists I had seen while remaining undiagnosed.) Finally getting a diagnosis and starting treatment can only be beneficial to all parties involved.
Waiting to hear from you, XXXXXXXXX 18 pages enclosed ------------------------------------------------- Do I need to add or change anything? I will start work on the other appeals soon.
cantgiveupyet
Frequent Contributor (1K+ posts)
Member # 8165
posted
I think that is a good letter and hopefully will help to win your appeal. Good luck and dont give up.
I agree with Daise- What gets approved often depends on what clerk processes it. I have a few examples where I have gotten things approved at 100% that should have only been approved at 80%.
But on the otherside, I have received less for some LLMD visits. After awhile you learn some good tricks that help you deal with your own insurance company.
I see you had some testing done with Genova, I havent had any luck getting any tests paid for that Ive had done with Genova. My insurance company called them 'experimental'.
-------------------- "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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Tincup
Honored Contributor (10K+ posts)
Member # 5829
posted
Hey want...
Looks GREAT to me! Good letter! I see nothing that needs to be changed.
Please let us know how it turned out! And if you need any more info. But it looks like you did great here.
posted
I had posted info re. insurance reimbursement for specialty medical testing. It may have been removed.
Here are some important points: 1. Medical necessity. It would be helpful if your provider would write that these specific medical tests by these specific laboratories are 1. medically necessary, and 2. in their medical opinion, these tests may offer more precise diagnosis. In turn, faster and more accurate diagnosis and treatment.
You may want to point out the following in writing- also, be sure to point out that you are not a doctor, lawyer or etc., but you would like to bring the following concerns and QUESTIONS to the attention of the health insurer's medical and legal personnel:
1. More prompt and precise treatment may lead to lower costs -lower overall claim costs and less opportunity for disease progression and the need for taxpayer funded assistance.
2. The importance of using antimicrobials wisely. Under-treatment, over-treatment and/or misdiagnosis may waste scarce health care resources.Underdiagnosis and/or under-treatment of communicable infectious disease is contraindicated in most circumstances. When a patient is not diagnosed or misdiagnosed, they might for example, donate blood. This can impact the blood supply, so it is important to promptly, correctly and completely diagnose infectious disease.
3. Different infections may require different types of antimicrobial treatment. Medical treatment with the wrong antimicrobial and/or under-treatment may precipitate pathogen mutation and/or treatment resitant pathogen strains, so it is important to correctly and completely diagnose and treat communicable infectious disease.
4. Specialty testing may offer a better yield than routine testing. In a number of cases, standard labs are outsourcing medical test kit components and assembly to India and/or China. You might want to point out that you are not sure that these medical tests meet CLIA and/or FDA requirements. You are concerned that these in-network tests may have a higher rate of false negative, and that this may lead to your health insurance plan and others being over-billed.
You might want to carbon copy the letter:
A. In the case of a small business plan or individual plan, you may want to copy in your state insurance bureau.
B. If the plan is sponsored by a large company, you may want to copy in human resources, a senior company official, or a union official (if applicable).
This is also an election year, so copying in an elected official who is up for re-relection may also be a consideration.
Hope that this helps-nannie
Posts: 183 | From US | Registered: Feb 2004
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map1131
Frequent Contributor (5K+ posts)
Member # 2022
posted
wantabe, I finally gave up fighting my insurance company and just paid for everything myself. I know that's not what you want to hear, but I didn't have the strength or power to fight them anymore.
They rejected everything my LLMD did. Thank goodness my script insurance was ran by a different group and they helped pay for all scripts. LLMD had me on some pretty expensive rx's for some of those tests results.
So I just took that and did what I needed to do. I would tell my LLMD I can pay for this or this on each visit. He completely understood money and being able to pay for these expensive tests.
Pam
-------------------- "Never, never, never, never, never give up" Winston Churchill Posts: 6478 | From Louisville, Ky | Registered: Jan 2002
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posted
Another all-call for information to send to insurance company. I sent in my 1st appeal on the IGX tests and am waiting to hear back (not holding my breath) Thanks to all that helped with this!
I have collected some information on the other tests (posted earlier), but would love any other researched tidbits to throw at them.
I have searched under other dx problems as well as Lyme. They include: Erhlichiosis Raynauds chronic fatigue Hormonal deficiencies Nutritional deficiencies Sleep disorder
Is it a good idea to include these and their data or just go with Lyme?
Really need help showing why different infectious disease panels were ran- you would think this was a no-brainer, but not easily finding supporting materials.
Bad head days have slowed up my research and I'm wanting to get this to them ASAP.
Thanks for any and all help! Wantabe...done with this
Posts: 235 | From Iowa | Registered: Feb 2008
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posted
OK- letter up for peer review...sending tomorrow-thanks for any input!
I'm hoping this will cover the remainder of tests that are being denied:infectious/viral/nutritional
After required information and same intro as 1st appeal...
The tests that were performed on xx-xx-xx and sent to Redlabs were necessary to diagnose and start treatment on an active case of Lyme (b. Burgdorferi) and coinfections. Physical symptoms, examination, and documented history of medical problems were used to determine what tests were needed to be administered to diagnose and start treating my infections and deficiencies.
After test results were examined by my physician, treatment began and improvement in my debilitating physical state is beginning. Without these tests, I would still be undiagnosed and unable to begin my recovery. I would still be seeing specialist after specialist trying to find an answer.
I have included many researched and cited resources for you to review to help you understand why the tests were necessary. Lyme and coinfections are often undiagnosed or misdiagnosed when testing and clinical examinations are not performed.
After my initial examination on xx-xx-xx and meeting the initial CDC diagnostic criteria for chronic fatigue syndrome, testing was ordered to rule out or identify other possible causes of illness. ``Chronic Fatigue by definition represents a diagnosis of exclusion. Late stage or "Chronic Lyme" infection with or without "co-infections" is a difficult diagnosis to establish. The symptom complex of both conditions can be very similar.'' Journal of Chronic Fatigue Syndrome. Vol. 13(4) 2006
The tests performed on xx-xx-xx were used to exclude or diagnose a medical condition. My debilitating condition took me from my family physician and the ``majority of medical trained physicians'' to specialists in Rheumatology, Neurology, and Infectious Disease. Many specific and exclusionary tests had already been ran at both University of Iowa Hospitals and Mayo Clinic, MN with no answers. (See past history)
The tests ran on xx-xx-xx continued the necessary and specialized search for a diagnosis, and were deemed medically necessary for my treatment by my physician. These testing procedures are not excessive and repetitive. On the contrary, they were used instead of the more invasive testing as the Mayo Clinic was considering. (See enclosed documentation)
Please let me know if you need more information to help you understand the complexities of diagnosing chronic fatigue syndrome, Lyme and its coinfections. This has been a long journey for me. Finally getting a diagnosis and starting treatment can only be beneficial to all parties involved.
Waiting to hear from you, 23 pages enclosed
I have contacted my state representative-He is contacting them as well. He didn't know much about Lyme and its politics/problems before I sat down with him...was very interested.
only thing i would have added at the end is that i have contacted Iowa's Rep/Senator, ...., and they will be in touch with you also.
putting headlock of someone overseeing them, and then iowa insurance commission if you are denied! *************************************************
don't let them draw this out forever either; my co. bounced me around lying to me for 18 months; after 8-10 months, i got the iowa insurance co. involved, and worked directly with their ATTORNEY! didn't help me, but you never know! Betty
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posted
Agree with Betty! Not too late to send copy of appeal, along with a letter to each of your senators and your representative. This also serves to put a face on the legislation before them regarding lyme disease and the controversy surrounding diagnosis and treatment.
Remember that insurance companies expect most people to accept their ruling and not challenge them! I even challenged my company with using misleading language and won (I knew that English degree would come in handy someday). Of course, they came out with a clarification of that section for '08; but I plan to challenge that as well. These people wield too much power - we need to dethrone them! Don't give up!
Posts: 422 | From Herndon, Virginia | Registered: Oct 2005
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Sent appeals with 24 pages of sources and information. Didn't add the legislator information. State Rep. said he was going to contact them soon-he will. Thought giving them a warning would be too nice.
Still haven't heard from my first appeal with IGX tests. Think I'll call tomorrow... good thing I'm still working 1/2 time-this insurance circus is a full time job!
posted
you bet it is fighting insurance co. is a FT joke! i spent 18 months fighting mine!! LOST! ********************************************
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METALLlC BLUE
Frequent Contributor (1K+ posts)
Member # 6628
posted
Update? Did they get the letters and reply?
-------------------- I am not a physician, so do your own research to confirm any ideas given and then speak with a health care provider you trust.
Sent in 3 different written appeals with more and more information-no go
Denied all!!
Cannot appeal further because I'm a government employee (public schools) and part of a self-funded group insurance group.
Could contact lawyer and take to court, but I'm sooo tired- not sure if it is worth my limited supply of energy.
Good news but doesn't make any sense... Paying for LLMD appointments and all treatments that are regularly covered by insurance. This has included iv treatment for the last 3 months.
I think the information sent made a difference on this part of the claims-THANK YOU all that helped!!!!!
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