Topic: Insurance denial of IV rocephin in NY state--who got it covered/overturned?
Rumigirl
Frequent Contributor (1K+ posts)
Member # 15091
posted
Does anyone have experience getting IV treatment covered or deniaIs reversed in NY state?
I have Oxford, and they covered two months of ceftriaxone, but have denied any further treatment, saying "it's not the standard of care, it's experimental." Decision rendered by an Infectious Disease duck.
I appealed the denial, using CALDA's letter about the two standards of care, Blumenthal's Press Release, a letter from me, a letter of medical necessity from my LLMD, office notes, and lots of studies & ILADS guidelines, provided by my LLMD's office.
They upheld the denial, and completely ignored everything I sent in the appeal, even getting my history of treatment wrong.
I am going to appeal again. I can either file a second level internal appeal or an external appeal with the NY State insurance board. I think I'll do first the internal, then external appeal, as the external appeal is binding.
I filed a complaint with the NY State Attorney General's office, but they sounded like they couldn't do much, unfortunately. I called Blumenthal's office, since Oxford is located in CT, but they can't do anything, because I'm in NY.
Any other suggestions/feedback? I know lots of people, including others with Oxford, who are covered long-term, no problem. It's frustrating. LLMD's said I'd be lucky to get one month's worth covered.
Posts: 3792 | From around | Registered: Mar 2008
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posted
I dont really have much to add except good luck. I am just starting the fight myself in NY. I have Empire Blue Cross.
Keep fighting as far as you can go. Most people stop after the first round or two...be persistent and do not give up. You can take these appeals a long way.
I was told by someone who worked for Empire for 15 years that the people who went all the way usually won their appeal.
I have just started the process. I just sent in a note from the LLMD which of course will not mean much. They haven't denied the claims for IV yet they are asking for more info at this point which my LLMD is not real forthcoming anyway.
So I just wanted to say good luck, keep fighting and do not give up. We have a chance with this.
Deb G
Posts: 499 | From Malta, NY | Registered: Dec 2008
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posted
We also have Oxford. Unfortunately they have not payed for any of my daughter's IV abx beyond the inital 28 days. I've appealed the decision(s) several time and have gone to external review twice already.
They continue to request a spinal tap to approve more IV, however she's already had 2 spinal taps that were negative and I'm not going to subject her to the trauma of another one, when it is likely it will be negative too.
My daughter has CDC positive tests from Stonybrook lab for Lyme and Babesisosis, severe Hypoperfusion on her Brain SPECT scan, abnormal MRI, peripheral neuropathy on Nerve conduction tests, letters from 2 LLMD's and one Neurologist stating she needs this treatment... and we also have a picture of her EM rash.... none of this is good enough "proof" for them, I guess.
I've spent many hours on the phone with the people over at Oxford, yet have gotten nowhere.
I hope you have better luck than we have...
God bless.
Posts: 371 | From CT | Registered: Jun 2008
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bettyg
Unregistered
posted
hi all,
lately i read something, not sure if it's about THIS type of appeal or not, but call & request they send you a copy of their rules/guidelines on this that they use to determine whether to approve or not.
again, this went by me and since i read so much; that's all my neuro brain will remember presently!!
posted
I am gearing up to start my appeals with bc/bs in New York. Ny is the pits for lyme and so is bc/bs. I haven't started yet, but I already know they will only pay for 28 days.
Posts: 847 | From upstateNY | Registered: Dec 2007
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Rumigirl
Frequent Contributor (1K+ posts)
Member # 15091
posted
JKMMC09,
Get in touch with Attorney General Blumenthal's office, the Health Care Bureau (or whatever they call it). They should be able to help you.
What an outrage! Have you used CALDA's letter as a prototype about the two standards of care, along with Blumenthal's press release about the IDSA settlement? Also, ILADS guidelines?
Unfortunately, I sent all that in my appeal, and Oxford completely ignored all of it. As I said, they even said that I had had 6 weeks of Bicillin and doxy as a reason to deny me further treatment. But my LLMD"s notes clearly state that I didn't get anything like 6 weeks, because I couldn't tolerate the doxy, due to daily migraines from it.
In addition, I had a new engorged tick bite over Memorial Day weekend. I'm gearing up to do the next level of appeal. It's hard to know if another internal appeal is a waste of my time and energy or not. Probably, but I'll probably do it anyway, just to have one more shot.
Posts: 3792 | From around | Registered: Mar 2008
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