How to fight against insurance denial for Stelara

[Mark in Seattle]

Hello,

My dr. submitted a prior authorization request to my insurance companies last month to switch me from Humira to Stelara. CVS approved the monthly injections, but Unitedhealth denied the initial infusion. United said they denied due to lack of information. My gi had a "peer to peer" phone call today with United's doctor who denied it. And apparently following the dall, United is still denying it, while my doc's office is now filing an appeal on my behalf. My doc's office tells me that this is typical insurance protocol, to summarily deny until they get worn down by appeals, etc.

All I can say is that I am really angry. United hides behind boilerplate language which does not convey anything at all in terms of an actual rationale for denial, and they have their generic customer svc reps that tell you nothing.

I am wondering if anyone has any suggestions on how to fight this kind of problem? Use a lawyer? Use US dept of Labor (since my company's plan is self-insured/funded)? Any tips/advice at all?

If they deny my dr.'s appeal, then I really don't know where that will leave me.

 

[Lisa]

I would think if you have been on other medications and they are not working the insurance company sound approve or, at least eventually.....I also have United Healthcare and knock on wood they have been great about approving remicade for me.......

 

[RNGirl]

Hi Mark, call United and request a "Complex RN Case Manager". Right now you are a subscriber number and not a real person to them. It would be helpful to have a real person to contact and be your advocate. Plus she is a nurse and will understand your needs and be your point of contact when you call UHC. All insurance companies have RN Case Managers and they are usually seasoned well schooled nurses. They usually send you a consent to agree to their services (the case manager). Be persistent till you get one assigned to you. Insurance has these nurses to manage complex high risk patients like us. This service can make a world of difference and she will speak to the doctor too. Good luck!!

 

[Mark in Seattle]

It's kind of odd because somehow my prescription meds are handled thru CVS while my medical stuff goes thru United. CVS already approved the subsequent injections while United is thwarting the whole deal by refusing the initial loading infusion to be done in the hospital. So now I have no Humira and no Stelara.

Talke to my today, minutes after he spoke to United. He advised me the talk went well and he expected an approval. Couple hours later I called United and was informed that the phone call did not help my case and that United had officially upheld the denial.

.&$@???

My little rant.

Anyhow, thanks Lisa.

And thanks RNGirl. United recently assigned a nurse to me; she likes to call me and chat and offer advice like buying diapers for myself. I have no idea if she is a "complex rn case manager or not. On our last conversation she said something alomhpg the lines of her having no influence in such matters. I had a scheduled meeting with her today but did not take her call, as I was too pissed at United. I will call United tomorrow though and ask about a complex rn case manager.

 

[my little penguin]

Since the infusion is in the hospital the medical side of your insurance covers the infusions just like any other hospital procedure and drugs given like Stelera are part of that procedure
Once it's just home injection then cvs would be covering the prescription only

If your health care is self -funded by your company
Then essentially united just manages the policy as an administrator
Your company dictates the policy
Your company can request a special exception to the policy for you
Sometimes they do and sometimes they don't
Might be worth talking to your hr manager

That is how one persons health benefits can vary greatly from another persons even with the the same "large group name"
Since your individual company picks what they want in a policy mostly based on company and employee cost

Good luck

 

[RNGirl]

Hi Mark, a lot of insurances are now denying infusions in a hospital setting, but will approve in a free standing or physician's infusion center. Does your GI do infusions at his office? It's of course cheaper in the office setting. Worth a shot at least to rule this out. I was told by my insurance that I MUST have the initial infusion at the hospital and not the physician's infusion center, but I work for the hospital. Just when you think you have insurance figured out they send you a curve ball. Keep fighting the battle!!

 

[Mark in Seattle]

RNGirl, so far, I have not heard any pushback relating to the infusion venue. We'll see. I know I spoke to a worker at the hospital infusion center in Seattle where I plan to have the infusion and they told me that it is important to have the infusion done at the hospital in case there is a reaction, so they can address it. I have had some really severe reactions to the thioprines in particular, and frankly have a phobia of meds in general because my body often reacts strongly to meds, perhaps due to psychosomatic/anxiety/who knows. But I do want to have it done where I feel properly looked-after, and the Seattle hospital is (I believe) the only option that my doc has offered. My doc did not mention any other options like you mention when I queried him.

Anyhow, I talked to United about the Complex RN Case Manager and they said that my already-assigned RN case manager is all they have; they don't have a "complex" version. So I spoke to my assigned rn case mgr today and she was trying to be helpful to me and she gave me some advice and sounded somewhat positive that the appeal may get approved.

Thanks for your support!

 

[Jabee]

I agree with my little penguin. I would contact Human Resources where you work and talk to them about your coverage. It's never a bad idea to have more people working on your behalf.

It would be useful to know why they are denying the initial infusion but the following injections are covered. Do they have a formulary in place where you have to try several different drugs before Stelara will be covered? And can you get information on what exactly your insurance covers? I have Cigna and log onto the website to check my coverage.

Best of luck and I hope things get straightened out fast.