Fecal Calprotectin Test Insurance Appeal

[crohnsinct]

T's post dx FC tests have been denied by our insurance company as experimental for the monitoring of disease activity.

Have you stopped laughing yet?

They covered her pre dx test to determine whether or not we should move to scopes (ie: to determine whether or not they should pay thousands of dollars for scopes) but now that she actually has a dx they won't cover the test. So they would prefer that we keep injecting her with mtx with the hopes that it is doing something and let simmering inflammation go undetected and then they will pay for a surgery!

More humor...the test is $118 but their negotiated rate is $18!

So of course I am appealing. I am getting together some literature to include with my appeal and so far this one seems to sum it up.

http://journals.lww.com/ibdjournal/...rkers_in_the_Diagnosis_and_Monitoring.19.aspx

The CCFA has a template for an appeals letter. T's doc will also write a letter and include some studies.

Has anyone else had to fight such a denial? Do you have anything you used that you wouldn't mind sharing? Studies, papers etc?

Oh and the hysterical part in the one I linked to, they state the levels where it is indicative of inflammation and disease activity and a possible change to treatment...above 200. T's last test was 256...but we are going to ignore that part for now.

 

[my little penguin]

We had the same thing happen
Fc test was covered for three plus years even after dx ( same company same plan)
But the insurance company started a this is experimental thing this past Jan.
Got the same speech levels won't change treatment blah blah
Didn't seem to care that DS bloodwork shows nothing so that would leave us with much more invasive scopes again they didn't care.

Haven't started the appeal yet - since even though it's been denied I haven't seen a bill as of yet to appeal ......

 

[Mj1gaynor]

We had the same thing happen to us. The insurance company said that the only way to evaluate crohns was through colonoscopy. Our test from same dr. Cost $250. We have done 3 and none were paid! You reminded me we need to appeal them.

 

[crohnsinct]

Mj - I know we use the same doc...which lab did you use? CLP? They only billed me $118...oh and you can bet I called them. I asked if my insurance denied the charge if they would adjust the bill down to what the insurance normally would have paid (this was before I knew insurance only paid $18). The lab said no! They said the only way they would adjust it was if I had no insurance. I told them for intents and purposes for this test I don't...they didn't appreciate that. Send me a pm and let me know which insurance company, I don't want to trash any company in an open forum. The nurse/IBD coordinator in the office who has a daughter with IBD is fighting with the same insurance company I am in order to get the test covered. She has a consumer advocate for the Courant on it as well.

MLP: that cracks me up. They cover and cover it but all of a sudden it is experimental!

I will share whatever we decide to send with you guys and let you know what happens.

 

[Catherine]

Hi Guys in not a approved test in Australia either, it costs me $40. The other lab wanted to charge me $140.

 

[Pilgrim]

Beyond ridiculous.

 

[izzi'smom]

Wow-insurance companies are just unreal. Wishing you luck!!

 

[crohnsinct]

Even more humorous. I called the lab and explained the denial and that the negotiated rate is typically $18 which is what they were paid when we used the test as a screening tool. I requested they adjust the bill. They told me they adjust bills but only for clients without insurance. I told them for all intents and purposes I didn't have insurance for this test...they didn't see the irony and requested my prompt payment of $118.

 

[pdx]

So so frustrating! It just makes no sense...

 

[araceli]

Either none of the insurance companies covers the test or we all have the same insurance. We are on the same boat.

 

[crohn'smakesmeangry]

We used to have Blue Cross and they always covered the test with no issue. We have Cigna now and every time they do calprotectin I get a letter telling me the same thing- they don't cover it because it is considered experimental. The first time I called -very angrily- and they said they don't cover it but because I went to an approved lab, I don't have to pay anything. It is ridiculous! I don't see why you could not have Dr bill the test without your insurance and just pay the $18. We ask the pharmacy for some medications the price w/out insurance and if it is lower we do it w/out. It's your insurance so if you don't want to use it you shouldn't have to!

 

[Jenn]

bumping this cause it just happened to me... The FC was always covered before but without any notification is suddenly 'experimental'. I appealed, it was denied. A 'family medical doctor' reviewed the case, um, why not a specialist? Every item they state is in contradiction to my appeal letter's points, I really don't understand that. Our cost is $221. What really gets me is not notifying people of the change, a simple letter saying, 'hey, you've had this done in the past and it's no longer covered' would've been nice. Also galls me that they happily charge struggling patients and their families the full amount but the greedy insurance companies get the break... grrrrr. Our insurance has always been great, but it seems they are all declining now, cutting corners to keep profits up. Clearly, once one insurance company gets away with not covering it, they all bandwagon.

 

[my little penguin]

You can ask for your doctor to have a peer to peer review
Which means they have to find another specialist
But also means your Gi has to be willing to take time out to "talk" as well
Not sure that would work so well for fecal cal

 

[kimmidwife]

I keep hearing this from people all over seems to be a new thing insurance companies are doing. I think the GI's need to get together and protest this!!!!

 

[CrohnsKidMom]

Experimental?! So frustrating! Sorry to hear so many of you are going through this.

 

[CarolinAlaska]

I second the peer to peer review. As a PA I've had good experience with that.