Policy #: INFECTIOUS 001.5 T2 Coverage Statement: Policy is applicable to: Commercial plans AARP MedicareComplete, Evercare Plan DH and SecureHorizons MedicareComplete, including Group Retiree Plans underwritten by Oxford Health Plans (NY/NJ/CT), Inc. (CMS Contract Numbers: H0752, H3107 and H3307)
quote:Recommendations for antibiotics are based on the guidelines of the Infectious Disease Society of America. Refer to: Treatment Regimens for Lyme Disease
quote:For Connecticut Commercial Members only who meet criteria listed in Treatment /Application Guidelines:
Oxford will cover initial Lyme Disease Treatment for a maximum period of 8 weeks for intravenous antibiotic therapy or oral antibiotic therapy. Initial intravenous antibiotic therapies require precertification.
Additional days of therapy will be covered upon receipt of a written recommendation from an eligible provider and are not subject to precertification.
Eligible providers are limited to physicians whom are board certified rheumatologists, infectious disease specialists and/or neurologists.
All Other Commercial plans: Further treatment of the above IV antibiotic therapy beyond 8 weeks must be reviewed and approved by an Oxford Medical Director.
[ 30. October 2008, 09:34 AM: Message edited by: AliG ]
-------------------- Note: I'm NOT a medical professional. The information I share is from my own personal research and experience. Please do not construe anything I share as medical advice, which should only be obtained from a licensed medical practitioner. Posts: 4881 | From Middlesex County, NJ | Registered: Jul 2006
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bettyg
Unregistered
posted
hi ali,
your post went super wide. when looking at it, looks like the LONG URL at the very tail end is what caused this.
could you copy it to www.tinyurl.com and then edit yours showing only tinyurl and deleting the really LONG one??
big thanks! look forward to reading what you discovered...
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Keebler
Honored Contributor (25K+ posts)
Member # 12673
posted
-
Just in case someone brand new to lyme is reading this, the statement at the end of the first post saying " . . .IMO, is just as Lyme-friendly as the IDSA guidelines. . . " means that the IDSA guidelines are not friendly to those with lyme.
See www.ilads.org for the ILADS treatment guidelines and, of course, the Newbie threads at the top of the medical forum.
--
Although insurance companies would not agree (nor the IDSA), this is an excellent article:
posted
Hey Ali I think this still only addresses the newly infected patients. But at least they cover 8 weeks without "precertification" or review by the Oxford Medical Board. But still restricted to three specific types of physicians. There is nothing here to suggest they treat Chronic Lyme. In fact - it just sounds like the same old stuff to me: "For Connecticut Commercial Members only who meet criteria listed in Treatment /Application Guidelines" I think they are refering to the IDSA (Deerborn) criteria: -must have an EM rash confirmed by physician
"Eligible providers are limited to physicians whom are board certified rheumatologists, infectious disease specialists and/or neurologists." (looks like your PCP or LLMD are not Eligible, unless also one of the above)
-confirmed positive result first by ELISA screening -confirmed positive Western Blot (by CDC standards)
I wouldn't get your hopes up. -p
Posts: 641 | From So. CA | Registered: May 2008
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AliG
Frequent Contributor (1K+ posts)
Member # 9734
posted
Sorry Betty, Type-o when posting link. I fixed it.
Great idea Keebler - Thanks! This would likely be a topic that would garner newbie attention.
Peedie- My hopes are not up. I am highlighting the dirt and trying to compare the evils.
Actually BC/BS-NJ requires "review" for extension past 4 weeks. IME - Review=denial.
I'm wondering if the cost of insurance actually justifies the (lack of) benefits.
If anyone has had an insurance company pay for long-term IV therapy, I'd really appreciate their name (and State where approved, because benefits vary by State). I can add them to the list.
I thought it might be beneficial to do a compare/contrast of different companies' policies, restrictions and requirements.
It's kind of hard to figure all this out alone. Maybe if we work together we can pull something together.
As a newbie, I had tried to find info on insurance coverage, looking for Drs etc... It was VERY frustrating.
It looks like there's an Act that Sen Connors introduced in congress 5/2008, trying to mandate Lyme coverage in NJ. It doesn't look like anythings happening with it though.
-------------------- Note: I'm NOT a medical professional. The information I share is from my own personal research and experience. Please do not construe anything I share as medical advice, which should only be obtained from a licensed medical practitioner. Posts: 4881 | From Middlesex County, NJ | Registered: Jul 2006
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posted
CT has a law about treating lyme, which accounts for the description here. Some say this law was helpful, but others say it isn't because of the restriction on kind of doc to certify treatment is needed. I believe Dr. J in CT feels the law is not as helpful as it could be, which may in part be why the board went after him. He tells the truth, and got into hot water as a result. He also treats according to his conscience and the needs of the patient, not by insurance restrictions.
Those who think that requiring everyone to have health insurance, like MA did, is the answer to the healthcare crisis needs to remember how their insurance company has behaved about their lyme treatment, and the role they have played in taking out lyme doctors.
Posts: 8430 | From Not available | Registered: Oct 2000
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I have Oxford, my daughter has a CDC pos. ELISA and WB from Stony Brook lab, Demeylinating Polyneuropathy shown on EMG Nerve conduction studies and biopsy, arthritis in BOTH knees-fluid tested in one... she also has a "Severe" SPECT scan, showing global hypoperfusion.
She has seizures, many neuro. symptoms, very ill.
We are paying for IV out of pocket, they would not even cover 8 weeks. They continued to request another spinal tap be performed to "rule out" other diseases. My daughter has had 2 spinal taps, negative for Lyme and other causes. She developed a leak after her last LP and was hospitalized for a blood patch...why would I put her through that again, when Lyme has been neg. 2 times before!?
It's such a shame the way this disease is treated by the medical community and insurance companies alike.
I believe my daughter has more "objective" findings of Lyme than many on this board, am I wrong? I was shocked by the denial...
Posts: 43 | From NY | Registered: Oct 2008
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posted
JKM03 I certainly would not put her through the spinal test again. It's almost like they want to collect more "see - this is negative result" tests to impress anyone (naive or otherwise) reviewing your case to reject your coverage claim. Yes of course your daughter is the "poster child" for the disease with the CDC positive result and clinical illness typical of Lyme Disease. There is a process to dispute your insurance provider's decision. I don't know the process but there are many posts here to help you and there is a link under "Newbie Package" which would be of good help to you. When my own daughter got a spinal tap - hers leaked also. I know what you went through. The intense pain our poor little girls went through. It is heart wrenching. I felt so helpless and guilty for allowing the proceedure. TC -p
Posts: 641 | From So. CA | Registered: May 2008
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posted
I don't know what kind of test they ran on her CSF, but here are the results published by Mayo on lyme testing:
Diagnostic Microbiology and Infectious Disease
Ngolela Esther Babady, Lynne M. Sloan, Emily A. Vetter, Robin Patel, and Matthew J. Binnicker
Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
Abstract
We performed a retrospective review of 23,777 specimens tested by our Lyme real-time polymerase chain reaction assay to determine the percent positive rates by specimen source. The percent positive rates were highest in synovial fluid (6.4%) and tissue (6.5%), and lowest in blood (0.1%) and cerebrospinal fluid (0.09%).
Maybe they weren't even testing for lyme, but "other things" that her symptoms could be blamed on. Or maybe they were just stalling with endless testing, when none of the possibilities would produce this kind of multisystem disease. Really, I think all this proof that is demanded from ins cos is not honest, not a real attempt to find the culprit, but just a way of saying no without actually saying it. Creeps.
Posts: 8430 | From Not available | Registered: Oct 2000
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AliG
Frequent Contributor (1K+ posts)
Member # 9734
posted
Thanks Lou.
This is exactly what TICKS ME OFF!!!!
How can they try to say that a dangerous and painful procedure is necessary for proof when the positive rate was .09%?!!!!
They know that not many people would agree to it & therefore they are free to use it to avoid appeal. They figure that people will just give up rather than risk additional infection or paralysis for the odd chance that they may have to pay.
Such a requirement means that, if EVERYONE complied, they would only have to pay claims for 9 out of 10,000 valid cases.?? THAT'S ABSURD!!!!!
The fall-back alternative? Neuropsych testing. It's not too hard to get a duck in their pocket with that one and I believe they will require you to go to one of THEIR doctors.
It is a proposed Act to change what these companies are getting away with in NJ. I think we should all get behind this & make sure it gets through.
If we can take them down in NJ, then residents of other States can use it for example to get their own State legislature to deal with this problem.
I intend to write a note of thanks and offer of support to Senator Christopher J. Connors ([email protected]). I'm going to try to find out if there's some way we can help this along.
I traced this back & he's been trying to get this passed since 1998. He's reintroduced it in 2000, 2002, 2004, 2006 & 2008.
-------------------- Note: I'm NOT a medical professional. The information I share is from my own personal research and experience. Please do not construe anything I share as medical advice, which should only be obtained from a licensed medical practitioner. Posts: 4881 | From Middlesex County, NJ | Registered: Jul 2006
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