Denied

[Michaela]

I received my letter from United Health Care (United? United to what? Certainly not help) saying they decided to uphold the original pre-authorization denial for medication Fentora saying it's to be used only for FDA malignant cancer pain. While I understand cancer is painful, so is nerve pain and ass pain and it's compounded by the fact that I don't have the luxury of transferring by myself whenever I want. How can they do this to a person? This country's insurance industry is leaving people in crisis so the CEO's can get multi-million dollar bonuses. It is disgusting. I wrote a letter explaining my entire situation and my DR wrote a statement confirming the need, diagnosis, etc. I guess being an unproductive member of society is what they want.

M.

[Broknwing]

does it have information for how to appeal the decision? I just got a denial from AARP for the quantity of sanctura I take for my bladder and it has all the info and reqquirements for an appeal...I now have to call my dr to see how to handle this...if it's got appeal info, follow up on that....

[metronycguy]

you have absolutely nothing to lose by writng letters to appeal it. write your state insurance board too

[dan_nc]

/wrte to appeal uit . it doesn't hur tand you have a limited amount of time to write to appeal their decisoun. just state as much facts as you can/

[darkeyed_daisy]

I hate to say it...but I could see this coming. I got a letter a while back denying 60 darvocet n-100's a month that I havent taken in well over a year. Apparently 60 is too much for a month....my doctor kind of laughed as Darvocet never helped my hip pain anyway but they felt the need to send me a letter telling me that if I needed this prescription again that my doctor would have to document why I needed it.

IS SCI NOT ENOUGH FOR THESE PEOPLE?

Someone at the insurance company has been deciding for many years whether you need inpatient treatment based on the diagnosis and signs/symptoms you present with. It really sucks now that they are going to be doing the same regarding the meds we need to survive pain and bowel/bladder problems too. So now when we flood our doctors with requests for paperwork to justify these meds (which is already in the records anyway)....docs are just going to eventually stop taking medicare and medicare advantage plans.

My doctor really tries to prescribe meds that my plan will approve or that is on the formulary. She goes out of the exam room and back to a computer and makes sure each drug is on the list. Now imagine her doing this for the 20 or 30 patients she sees or takes calls from a day all with different insurance carriers. I realize this is not the norm for all doctors but I really really appreciate the effort that she gives her patients. It really pisses me off to know that someone at the insurance company is going to be looking at my two or three diagnosis and then deciding whether it meets their definition of medical necessity. They dont know me......at all!!!!!! It just means more money out of our pockets because people like Micheala still need the drugs to live with this injury....

So I imagine the Medicare part D drug program is not all our president and congress praised it to be now is it??? Programs always look good for the first couple of years until they start phasing in the changes....

My doctor prescribed Ultram ER for me now and some days I need 200mg and some days I can get by with 100mg. My humana Medicare Advantage plan will approve either 30 of the 100mg pills or 30 of the 200mg pills a month but not 60 of the 100mg pills. Where is the reasoning for this?????? So we have snuck by this by having a prescription for both and whichever I am running low on is the one I get filled for the month.

BTW: When I called Humana (just for kicks as I was already taking a stronger pain med), they did not have a specific form or list of elements the letter from the doctor had to contain (ie...medical necessity for the drug). All the rep would tell me was that the doctor had to tell them why I needed two darvocets a day so they could make an exception determination.... Now this is exactly how medicare works on the billing end. They never tell you why it is denied, just that it is denied and not medically necessary. So if you ever find the right combination of code and modifier that they they will pay....you have to remember it. LOL

[Michaela]

I plan on appealing until the entire process is exhausted, no question. I am enraged however to the point of irrationality when I think about how absolutely shitty American health care is. Why is a DR's prescription no longer adequate? Why must I beg? I pay monthly premium, I am not some drug-seeking lowlife. I'm just a regular human being trying to make the best of an absolute shit situation. I wish these motherfuckers could spend a week, just one goddamned week, in my chair, in my 'life'. See if the pain would cause them to go insane. For fuck's sake, if all I had was malignant cancer, I'd know my suffering would soon be over and I could still wipe my own ass.
Insurance companies should just tell it the way it is: they don't want to pay because it affects their bottom line. And, we all know this country's religion is not found in some church but rather in a bank since we worship the almighty dollar.

[Michaela]

Furthermore, my blood begins to boil when I read stories like I do at websites such as www.healthboards.com (http://www.healthboards.com) about some whiny AB who has a slipped disc or somesuch nonsense and they whine because their DR won't Rx them 110 Actiqs a month to feed their somatic pain issues. I know it's logically impossible to draw parallels but it's NOT RIGHT!

[cheesecake]

You might want to try to get a letter of "Compassionate Drug Use" from the FDA for this medication. Reality is that meds are perscribed "off-label" all the time. In order to control costs, the health industry now denies the drugs based on diagnosis. It bites big time.

Good luck