More approval... must be something in the air

Well, after a battle with Coventry Healthcare of Kansas, I received a phone call today telling me that my appeal had been approved and that I would be able to get coverage for a CGMS. I may be the first person that Coventry has approved for such device.

What I really learned tho, is how an appeal process really works.

When you appeal, Coventry (and maybe other companies)will ONLY send the information that you include in the appeal. It is up to the reviewing doctor then to obtain other information either from Coventry or my doctor.

My initial claim for a 72-hr CGMS test was denied as experimental and the doctor seems to have simply assumed that I was a Type 2 based upon my age. He then proceeded to give me all sorts of evidence that CGMS systems were NOT experimental IF I was a T1 and on "intensive insulin therapy" (ie a pump). I provided that information (which my insurance company already had) and the test was approved.

I then applied for a CGMS device of my very own. The authorization was denied as being experimental, as I expected. I then appealed and quoted all the evidence from the previous denial that it was not experimental. They gave me all the evidence I needed to show that it was not experimental.

Basically, IMHO, the denial was automatic, the appeal process was a half-arsed and that is why they got backed into a corner and basically had to authorize the device.

So how to appeal from now on. Assume that the person reviewing the claim will NOT seek any additional information. Include any information that you feel might be applicable. Do not waste an initial appeal finding out why something was deemed experimental. Find out the basis of the experimental decision, preferably in writing, before you file your appeal. Most plans have 2 appeal levels, after that, it's off to court you go.

So, don't be afraid to appeal. Many people will get a denial and go "I really need that treatment, but there's nothing I can do". The insurance company HAS to explain the appeals process to you, it's the law. You may not always win, but at least you are fighting for what you need to live long, healthy life.

It only takes some time and patience to file an appeal. Get supporting letters of medical necessity from your doctor, gather all the information you can from every reliable place you can find it. Write a concise, non-emotional, professional letter that ties together all the information you are providing.

As a disclaimer, our insurance plan is s self-funded ERISA plan, which are regulated by the US Department of Labor as opposed to the Insurance Commissioner of your state. Being self-funded gives the plan-administrator a lot of flexibility in approving things since our company pays for the coverage, not Coventry. I asked our administrator today if she had spoken to anyone at Coventry about this and she said no, so it appears that Coventry approved this on their own. However, the story could have been different if the plan had been premium-funded. After a second level appeal, an ERISA plan requires the involvement of the Department of Labor to appeal past that point, I have no experience with that aspect.
If my plan had not been ERISA, after the second level appeal I would have then appealed to the Insurance Commissioner for the State of Kansas.

Remember, insurance companies make more money by not paying out claims. Sometimes denying a claim is justified, sometimes it is predatory. I've recently gotten very tired of predators.

Thanks for stopping by
Scott

Today's snarky comment:The day they teach computers to speak English will be the same day they discover no one speaks it.

0 members like this

Comment by Suzanne on April 15, 2009 at 7:13pm: Great news on the approval! I am getting trained on my CGMS next week. I didn't have to fight my insurance company much, I sent all kinds of paperwork (proving I was t1 and that this was a medical necessity for me) to them BEFORE I actually had DexCom start the process. One thing I found out from BCBS is that if you are part of their special programs for diabetics (the name varies from state to state) where a nurse calls you once a month and checks in on you and your diabetes, it is easier to get approved for stuff. They said I was "a compliant type 1" and therefore I could have the CGMS.

Comment by Kristin on April 16, 2009 at 2:26am: Hoorah on the approval!! Which CGMS will you use??? :)

Comment by Lois on April 16, 2009 at 2:41am: Scott:

Congrats! At least someone is getting insurance approval on something. I still haven't heard from my DR regarding his letter to the insurance company on the medical necessity of the pump. I'm not even asking for a CGMS!!

I hate this every-day struggle!!

Lois La Rose

Comment by Scott on April 16, 2009 at 6:27am: Suzanne, they had all the info already in their system. They have finally provided me with the name of a "case manager" who I can call about such things, but the CGMS was still an auto-denial to them, IMO. Not to mention the reviewing doctor made some pretty serious assumption about by medical condition without obtaining any other records... just frustrating!

I will be getting the Minimed, Kristin...

Lois, threaten to run the doc over with your nitrous-powered scoot if he doesn't get some results!

Comment by Josephine on April 16, 2009 at 10:34am: Scott, does this mean I can do more shopping ?

Comment by Scott on April 16, 2009 at 12:48pm: Knock yourself out, Jo, knock yourself out!

Comment by Suzanne on April 16, 2009 at 8:08pm: We should get awards for all the hoops we have to jump through just to get good health care, yeesh! I am an Olympic class insurance rules hurdler!

Comment by Scott on April 16, 2009 at 8:18pm: That's a helluva an idea Suzanne... maybe with enough awards I could get this bum knee fixed.

I use those insurance rules as tackling dummies... their kung fu is not strong

Comment by debb on April 17, 2009 at 9:18am: that's great scott,
glad to hear that you didn't have to fight too hard. and i'll bet you were all geared up and ready for a really good fight. i'll bet they knew better then to mess with you. lol !!!!