Denied...again
Since last Monday, I have been waiting for a phone call to let me know about the peer-to-peer review. I called the insurance yesterday, as the infusion center had wanted to know if they should cancel all of his appointments for this week. Insurance told me that they had outreached to our doctor, but there was no answer again. :( I called the nurse and left a message, indicating that the insurance was waiting for Dr. G to call back.
While I was in a session today, I saw my phone ring with a hospital number. I checked my voicemail after the session and heard the nurse's message..."Dr. G did have the peer review, and he wanted me to tell you that it was denied."
Seriously? I know that the treatments cost thousands of dollars, but it is a documented medical necessity.
She went on to tell me that the next step would be to appeal the decision, so I should send them all of the paperwork I have received from the insurance company regarding the denial.
I wanted to know more about the reasoning for the decision, so I followed up with the insurance company this afternoon. The representative told me that a peer-to-peer did in fact take place this afternoon, and she read me the notes: "Medical director called Dr. G and left direct contact information on his voicemail. Dr called back. Customer, five years of age, with bizarre behavior. Been given a diagnosis and treatment for PANDAS. Dr. not convinced. Thought Autism, but not convinced. Tried steroids this summer after NMDA encephalitis tests were negative. Well documented improvements on graphs and charts. However, no justification for treatment at this time."
My heart is torn in two. Everything we have done up until this point has no justification for treatment?
I gave the poor representative my sob story, and told her that I wouldn't ever put my child through procedures such as the ones recommended if I didn't truly think there was a medical justification for it. I told her how reputable Dr. G was, and how he didn't accept every patient. I told her that I couldn't afford the treatments out of pocket if insurance didn't help us.
And I told her between tears that this was the chance at helping my son. We have exhausted all options. We have gone to the top and received a recommendation that is only being stopped because of funding.
It seems so unfair that money unfortunately controls the fate of many. So many PANDAS parents out there, searching for the answer, the fix, the cure for their child.
The gut-wrenching part of it is that I have fought for three years to get a clearer picture of Hunter- and PANDAS was our hypothesis. So I pushed on, finding as many experts as I could to agree with the diagnosis and hopefully offer a treatment that would bring him back.
When the insurance companies see PANDAS, they are most likely to deny due to it being "experimental." And by adding PANDAS to his chart, I feel like I have hurt him, and not helped him.
When I was ending the conversation, my song, "Help me Find it" came on the radio. Was I surprised? Not in the least bit. I asked her if there was anything else I could do. She told me to have the doctor do another prior authorization with new dates of service, adding any new documentation, bloodwork, charts, etc. SO if we are denied after an expedited appeal, I will be advocating that for the next step.
I am overwhelmingly saddened by the denial. Every step along the way, I felt we were headed in the right direction. There was always a light, a ray of hope that I counted on to push me further. And now we have been stopped, in the midst of the end of the road.
Some days, and especially today, I have to stop myself from selfishly screaming THIS IS NOT HOW I PICTURED MY LIFE!
But then I have to remember, neither did he.
Just got out my daily devotional, and of course it is perfect for tonight: "October 3rd: When many things seem to be going wrong, trust in Me. When your life feels increasingly out of control, thank me. These are supernatural responses, and they can lift you above your circumstances. If you do what comes naturally in the face of difficulties, you may fall prey to negativism. Even a few complaints can set you on a path that is a downward spiral, by darkening your perspective and mind-set. With this attitude controlling you, complaints flow more and more readily from your mouth. Each one moves you steadily down the slippery spiral. The lower you go, the faster you slide; but it is still possible to apply brakes. Cry out to me in my name! Affirm your trust in me, regardless of how you feel. Thank Me for everything, though this seems unnatural- even irrational. Gradually you will begin to ascend, recovering from your lost ground. When you are back on ground level, you can face your circumstances from a humble perspective. If you choose supernatural responses this time- trusting and thanking me- you will experience my unfathomable peace."
Psalm 13:5; Ephesians 5:20
The Sidewalk Prophets have sung to me at the most opportune times, "Give me peace for the moment. Whatever your will, help me find it."
One of my friends gave me a new book, called Sparkly Green Earrings- she thought it would be the perfect read. Here is an excerpt, as the author is writing about the gift of having children: "How amazing that he brings life this way....such a striking picture of how Christ works in us. He takes our disappointments, rejections, and hard times, and he makes us something beautiful. He creates life and shows us what beauty looks like in places where we look and see nothing."
Humbling myself to have a supernatural, peaceful response of gratitude for my many blessings.
While I was in a session today, I saw my phone ring with a hospital number. I checked my voicemail after the session and heard the nurse's message..."Dr. G did have the peer review, and he wanted me to tell you that it was denied."
Seriously? I know that the treatments cost thousands of dollars, but it is a documented medical necessity.
She went on to tell me that the next step would be to appeal the decision, so I should send them all of the paperwork I have received from the insurance company regarding the denial.
I wanted to know more about the reasoning for the decision, so I followed up with the insurance company this afternoon. The representative told me that a peer-to-peer did in fact take place this afternoon, and she read me the notes: "Medical director called Dr. G and left direct contact information on his voicemail. Dr called back. Customer, five years of age, with bizarre behavior. Been given a diagnosis and treatment for PANDAS. Dr. not convinced. Thought Autism, but not convinced. Tried steroids this summer after NMDA encephalitis tests were negative. Well documented improvements on graphs and charts. However, no justification for treatment at this time."
My heart is torn in two. Everything we have done up until this point has no justification for treatment?
I gave the poor representative my sob story, and told her that I wouldn't ever put my child through procedures such as the ones recommended if I didn't truly think there was a medical justification for it. I told her how reputable Dr. G was, and how he didn't accept every patient. I told her that I couldn't afford the treatments out of pocket if insurance didn't help us.
And I told her between tears that this was the chance at helping my son. We have exhausted all options. We have gone to the top and received a recommendation that is only being stopped because of funding.
It seems so unfair that money unfortunately controls the fate of many. So many PANDAS parents out there, searching for the answer, the fix, the cure for their child.
The gut-wrenching part of it is that I have fought for three years to get a clearer picture of Hunter- and PANDAS was our hypothesis. So I pushed on, finding as many experts as I could to agree with the diagnosis and hopefully offer a treatment that would bring him back.
When the insurance companies see PANDAS, they are most likely to deny due to it being "experimental." And by adding PANDAS to his chart, I feel like I have hurt him, and not helped him.
When I was ending the conversation, my song, "Help me Find it" came on the radio. Was I surprised? Not in the least bit. I asked her if there was anything else I could do. She told me to have the doctor do another prior authorization with new dates of service, adding any new documentation, bloodwork, charts, etc. SO if we are denied after an expedited appeal, I will be advocating that for the next step.
I am overwhelmingly saddened by the denial. Every step along the way, I felt we were headed in the right direction. There was always a light, a ray of hope that I counted on to push me further. And now we have been stopped, in the midst of the end of the road.
Some days, and especially today, I have to stop myself from selfishly screaming THIS IS NOT HOW I PICTURED MY LIFE!
But then I have to remember, neither did he.
Just got out my daily devotional, and of course it is perfect for tonight: "October 3rd: When many things seem to be going wrong, trust in Me. When your life feels increasingly out of control, thank me. These are supernatural responses, and they can lift you above your circumstances. If you do what comes naturally in the face of difficulties, you may fall prey to negativism. Even a few complaints can set you on a path that is a downward spiral, by darkening your perspective and mind-set. With this attitude controlling you, complaints flow more and more readily from your mouth. Each one moves you steadily down the slippery spiral. The lower you go, the faster you slide; but it is still possible to apply brakes. Cry out to me in my name! Affirm your trust in me, regardless of how you feel. Thank Me for everything, though this seems unnatural- even irrational. Gradually you will begin to ascend, recovering from your lost ground. When you are back on ground level, you can face your circumstances from a humble perspective. If you choose supernatural responses this time- trusting and thanking me- you will experience my unfathomable peace."
Psalm 13:5; Ephesians 5:20
The Sidewalk Prophets have sung to me at the most opportune times, "Give me peace for the moment. Whatever your will, help me find it."
One of my friends gave me a new book, called Sparkly Green Earrings- she thought it would be the perfect read. Here is an excerpt, as the author is writing about the gift of having children: "How amazing that he brings life this way....such a striking picture of how Christ works in us. He takes our disappointments, rejections, and hard times, and he makes us something beautiful. He creates life and shows us what beauty looks like in places where we look and see nothing."
Humbling myself to have a supernatural, peaceful response of gratitude for my many blessings.
Comments
Post a Comment