Remicade Appeal DENIED

[rosee_posey]

Can you freeken believe it?! I've been turned down TWICE by Blue Cross Blue Shield, and I've got a LIFE-THREATENING case of Generalized Pustular Psoriasis!

Freeken Ay! How you figure!?

Doctors not happy either - calling in troops, including Joey at NPF.

I've got to keep fighting - I have NO CHOICE, other than death.

Isn't reality just interesting and dramatic? I just wish it were'nt me going through it....

- rose

PS: on bright side, I AM breaking some new ground here ;)

[makeitgoaway]

Don't hold back on sending letters to your State Commissioner of Insurance.

Actually, I would call first. Then they will most likely tell you where to send your complaints.

Good luck!

[chaimFL]

Damn BCBS.

Are you taking anything while you await further appeals??

You really should start on some kind of therapy before the pulstar p gets to aggressive.

I hope everything works out ok and you get the Remicade. Insurance companies just don't understand medicine and health so why the heck are they the ones that decide what's best for us?? :mad:

[Chikara]

I have BCBS and I guess they haven't decided to cover Remicade. But usually HMO's are the ones who usually deny everything and anything that could do some good.

But the NPF should be able to help, along with a letter of complaint to the Insurance Commissioner, and a letter of medical necessity from your doctor should help as well. But since your P is of a life-threatening calibur, I don't understand why they would deny it.

I guess BCBS is being quite anal. The healthcare system in Florida is terrible. Doctors are leaving the state in drones because they're afraid of getting sued and the healthcare system sucks. One hospital in particular could shut down rather soon, Orlando Regional's trauma center is short on everything and they really can't take too many trauma patients at one time.

But keep trying to get Remicade approved. I suggest reading over your policy carefully. If you have any questions, then don't hesitate to ask. I think it sucks that you can't get approval. I work in insurance and have since high school (well..okay 4 years really isn't all that much, but you tend to pick stuff up along the way) and I see and hear about things like this all the time.

Good luck.

[Allie]

Rose-

I am soooo sorry to hear of your denial. Insurance should not have the right to choose what is good for us!!

If it helps, BCBS of MI denied my Mom's repeated claim for emergency surgery co-pay of $2500. My Mom's emergency surgery could not be pre-approved b/c it was "EMERGENCY" & therefore by their policy should be covered 100%, not a % copay b/c it was out-of-network. The hospital was like, it is only $2500 on a $40K surgery, what is the problem - just pay it. When she did not pay it, they sent her to collections. At that point my dad got a lawyer involved...... After a short review of the policy, the lawyer put together a short letter explaining why their denial was in violation of the policy agreement. They paid the bill immed.

Review the policy and see if there are any loopholes. I am sure NPF will help you with that task. In the meantime, just try to keep you spirits up. (And if it gets any worse, have your Dr. stick you in the hospital - really make them pay! ;) )

Take Care,
Allie

[khorath]

Sorry to hear about this! I had my insurance company deny me coverage of Enbrel. I somewhat know how you feel.

My derm told me something, though, that made me think. He said if he (as a doctor) knows of a treatment but doesn't prescribe it (even if it is "off-label"), he can be sued for malpractice. I wonder why insurance companies can't be held to the same type of standard.

Of course, I think I know what their repsonse is. They say, "Well, you can take the drug - we're not stopping you. We are just not going to pay for it. If you want to take it, pay for it yourself."

Good healthcare should not be for the rich only....

Good luck in your fight.

[tvcats]

This stuff really ticks me off. I don't think insurance companies should have the right to deny paying for appropriate treatment prescribed by a physician. I hope you get this straightened out very soon. Good luck.
PS-- I am also fighting with BCBS right now because they have decided that my doc prescribes too many lab tests, etc. and so they're kicking him out of the network.
I HATE insurance companies!

[beladonna]

Insurance companies do not like going to court because most judges/juries side with the patient(victim). If they hear the word "lawsuit", they usually relent and pay. Can you imagine walking into court with a major pustular flare? Hopefully, it will not go that far.

Keep pluggin Rosey. The more you throw at them, the more it helps.

I know this does not compare to your situation, but I had a problem getting Principal to pay for my light laser therapy for my ps. They denied as experimental. Had NPF send some info as well as my doc and a letter from myself. I also stated in my letter that other carriers were paying, why werent you? Needless to say, my claims were paid that week. I did not have to pay a cent. It was alot of paperwork,but in the end, worth it.

I used to work for Major Medical and HMOS's. So, dont dislike me for that, we are all in the same fight.

Besides, now I just concentrate on Dental and Vision insurance. Its must less stressful.

Please keep us posted on your situation and I hope you are getting some other treatment until this gets approved.

[rosee_posey]

...it's not what you think.

It's in the thread called "Remicade Appeal Drama Conclusion."