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Insurance and the Games We Play – Redeux

** I originally posted this here on Sept 17, 2010.  The original post and comments can be found here.  I’m reposting it because I just received a letter from Coventry of Kansas (who is now owned by Aetna, I believe) that stated that all non-Lilly insulins are being completely dropped from their fomulary effective October 1.  I will require a prior authorization which requires a “trial and failure of a comparable Lilly product”.  Honestly, a treatment “failure” with insulin?  Really?  Gee, that doesn’t sound dangerous, does it?

When I first started pumping I was actually on Lilly’s Humalog.  What I experienced was the development of “fatty abscesses” at the infusion sites.  That resulted in poor absorption and eventually the insulin would just seep back out.  It was so bad, I almost abandoned pumping and stayed on shots. In that case, I image I would have probably stayed with my old habit of seeing an endo every decade or so.  Switching to Apidra solved the absorption issue and is what I currently use.

So that is what brought this post from two years ago to mind and it’s a decent refresher for me…

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 a 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 with the appeal itself. It is up to the reviewing doctor then to get other information either from Coventry or your doctor.

My first 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 first appeal review was 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 other 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 a 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 seems 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!

© 2012 Scott Strange, Strangely Diabetic and

  • Scott S

    I’m a bit confused when you say “Find out the basis of the experimental decision, preferably in writing, before you file your appeal.” Can you elaborate further on what that means? I suspect that at a fair number of insurance carriers, denial is virtually automatic initially because they know that will eliminate a certain percentage of possible claims for whatever it is they’ve just denied. Many won’t bother with an appeal, hence it’s a business practice that has nothing to do with health “care”. The issue of formularies is, IMHO, a joke. The deal is insurance company gets XYZ Pharmaceutical Co. to sell a product (like insulin) for a pennies-on-the-dollar cost (frequently Lilly, Novo or Sanofi will do it for an introductory period to land the account, then will jack prices up when that “introductory pricing” period is over. In much the same way as insurance companies may deny all claims initially for something, some insurance companies will then go through a request for proposal (RFP) process for a given product like insulin and seek to get a good price. That may require them to switch patients to what’s euphemistically referred to as a “therapeutically equivalent” treatment (instead of Lilly Humalog, they’ll cover Novo Novolog or Sanofi Apidra instead). In my experience, Novolog was “slow-mo[tion]-log” and I found regular insulin to be as fast, and sold for half the price without an Rx. I told my endo that I would not be switching to Novolog; I’d rather use Novolin R. Needless to say, I was able to get an exemption to continue using Humalog even with it not on formulary. But the B.S. patients must deal with regularly with for-profit insurance companies makes me wonder what kind of drugs those people who talk about rationing healthcare are actually using. To me, we already have healthcare rationing, the difference is who is making decisions about coverage.

    • Hi Scott, thanks for asking that, that is a pretty murky statement

      I know I have made the mistake in the past by sending in my appeal, usually just a letter of medical necessity, without discovering exactly the reason for the denial.

      You’ll get a letter with a pretty generic reason for the denial. If you don’t request the supporting documentation for the denial, your appeal may not address the actual reason of denial. The result is you basically “wasted” that first appeal.

      I agree, the rationing is already in place and for-profit insurance companies work to ensure profit.

      There’s a lot of discussion going on about “patient-centered care” and Accountable Care Organizations (ACOs), but really the model seems to be “payer-centered” and those payers seem to be awfully quiet in these discussions…