Insurance Question

[WindingRs]

I am curious how some kids get approved to use medicines not yet approved for pediatric crohns? My son did not respond to Remicade. Our doctor suggested Skyrizi or Stelara. We went with Skyrizi. Our medical insurance approved Skyrizi infusions. Now that it is time for injections, the pharmacy insurance did not authorize the injections- reasoning my son is under 18. Our doctor appealed, and we are waiting. Is there anything i can do to push the insurance?

 

[my little penguin]

For biologics that require the pharmacy side expect denial even if they approved it on appeal the year before
When the submit the prior authorization it is always denied for the easy check the box reasons
Then the doc has to appeal (always )
Sometimes it’s approved there
Most of especially if you haven’t been approved for the med before they require a second appeal (peer to peer - doc to doc )
Then you are good most of the time

but after tge prior authorization expires expect the same dance again

 

[WindingRs]

@my little penguin, thanks so much for the reply! Would it help if i follow up along with our doctor’s appeal, or just let it run its course? It is somewhat comforting knowing that it is a normal practice for them to refuse at first.

 

[Maya142]

Unfortunately, you just have to appeal. If that fails, you sometimes appeal again or you have a peer to peer review, where your child's doctor talks to a doctor from the insurance company and explains why your child needs that treatment. Sometimes you need to do multiple peer to peer reviews.

My daughter is on Remicade and while her prior authorization lasted till February, our insurance arbitrarily denied it in December. It took 3 peer to peer reviews because she is on the max dose (10 mg/kg every 4 weeks) and because she is on other medications for inflammatory arthritis.

We generally call our insurance company and follow up, make sure everything that needs to be sent to them has been sent (or we get it sent by the doctor's office).

There aren't many medications approved for pediatric Crohn's, so many kids are put on meds that are only approved for adults - Entyvio, Stelara, Skyrizi. So while they may deny the med initially, they will hopefully eventually approve it.

 

[my little penguin]

I have called the insurance when they defined my kiddos Stelara (after being on it for 4 years .
All that did was frustrate me -they would not be reasonable or listen to me

 

[WindingRs]

@Maya142, thanks so much for the reply! Had a bad morning today stressing about insurance. Hopefully things will work out.

 

[WindingRs]

@my little penguin, i totally understand.

 

[Pangolin]

Appeals are often successful. A very common situation is that the insurance company has specific requirements that must be fulfilled before approval. Often those have already been fulfilled, but the insurance company doesn't realize that yet. Once you specifically point out during the appeal process why those requirements have already been fulfilled, approval usually happens.

 

[crohnsinct]

We leave it to the doctor's office. They know what they are doing and deal with these appeals day in and out. Especially if they are a hospital doc. The hospitals generally have an entire department that does appeals for the docs. You calling doesn't mean anything to them. There is nothing you could say or do that will help them make up their minds. There is a specific amount of time they have to respond to an appeal (should be on your denial letter) and if that time has elapsed you could call them and ask the status but we find even there the doc's office is much more successful at getting information.

Sit tight. The denials are par for the course. A lot of the time is is just a simple form or fact that the doctor left out and they just have to make the insurance gate keepers happy by fi;;ing out their silly little forms.

 

[WindingRs]

Thanks! @crohnsinct, i will try to stay hopeful. I could not help, but calling them today which didn’t get anywhere.

 

[WindingRs]

@Pangolin Thanks! hopefully the issue is just the need for further explanations. Will keep you posted.

 

[Maya142]

I guess we are in the minority here (or just impatient!!) but my husband always calls. I typically call the pharmacist in the GI’s office who deals with prior authorizations to find out what stage we’re at and if she thinks it would be helpful for us to follow up. Then my husband calls insurance - not early in the process, but if it’s taking longer than it should or if we just haven’t heard anything. Often it’s a matter of the insurance claiming they do not have what the doctor’s office has sent over and whatever it is has to be sent again. Then confirming they’ve received that and once they have everything, they have a certain amount of time to review it. Sometimes we just learn the status (they’re waiting for a peer to peer review to be scheduled for example). I hate calling our insurance company because it is extremely frustrating but my husband is somehow very good at it and sometimes it’s honestly just making sure nothing has fallen through the cracks.

The pharmacists in the GI and rheumatology departments who do the appealing know us well and will often ask us to call to push on our end or to see what we can learn from our end. But we have 3 members in the family all who have been on multiple biologics so they know us really well!!

 

[momsa]

We have had a number of things that had to go to a "peer to peer." I also tend to call insurance after a while, and I also often get the claim that the doctor's office hasn't sent what I know has been sent. That's clearly one of their ploys, but the good news is that so far, we've always gotten approval in the end. The docs seem to know what they need to say to get approval, and I don't know whether my calling has generally made any difference, but what I do know is that I once managed to get the number of a supervisor who was actually very reasonable, and every time that my kids move to a different state (which happens quite often since they are in college out of state, gets summer jobs, etc), she streamlines the approval process in the new state so that they aren't late for their meds, so it has been worth my calling for that.

BTW, I resent the term "peer to peer" because they are not peers - it's our specialist in IBD who knows my kid talking with someone with a general MD that the insurance company has hired to cut costs.

 

[WindingRs]

@Maya142, i know my self, i will call again to make sure things are moving along . It is frustrating to have a kid with a chronic illness and deal with this insurance non-sense.

 

[WindingRs]

but the good news is that so far, we've always gotten approval in the end.

great to know. Since Friday that i found out pharmacy has denied the request, i am super anxious. I feel I shouldn’t have started the infusions until i had the pharmacy approval in hand.

“BTW, I resent the term "peer to peer" because they are not peers - it's our specialist in IBD who knows my kid talking with someone with a general MD”
I hear sometimes the other person does not even have MD

My daughter worked in a medical office, and she was telling me in one of the peer to peer reviews the insurance had denied a surgery asking to use medicine first for a particular condition. The doctor response was sure, please let me know which medicine because i am not aware of any medicine for this condition.

 

[Maya142]

We had that experience too - the last peer to peer our rheumatologist did was with an internist who had only seen a few rheumatology patients in his residency. I don’t understand how that is considered a peer to peer review!!

My husband also always asks to speak to a supervisor - that typically helps.

@WindingRs Has your child had all 3 infusions for Skyrizi? How long until the first injection is due?

How’s your son feeling on Skyrizi? Did he feel better with the infusions?

 

[WindingRs]

He got all 3 infusions - finished last Friday. He never had any physical symptoms before, except the draining fistula, which still is draining. We only found out about Remicade not working by labs and scopes. The disease had speared to his entire colon with zero discomfort!!
As for the lab numbers on Skyrizi, his CRP has normalized at week 8 of infusion. Hemoglobin also good now. Hoping for Sed rate to come down. Slightly elevated. Calprotectin stool test will be in 4 to 6 weeks.
We are lucky in that he does not have any side effects with Skyrizi. I try to stay hopeful.

 

[Maya142]

That’s wonderful news!! I think he’s the first kiddo on the forum who has been on Skyrizi.

Fingers and toes crossed that insurance approves his injections soon!!

 

[momsa]

Yes, wonderful news. With such a great response already, it should be hard for insurance to argue against continuing this.

 

[Maya142]

So looking at the dosing, it looks like you have nearly 4 weeks to get it approved. I agree, the fact that he has responded well to the infusions can be used to get insurance to approve the injections. Hopefully it’ll work.

 

[WindingRs]

IT GOT APPROVED TODAY! Fingers crossed it continues to work. I was in a panic mode all weekend! Thank you all for your kind words and feedback!

At our last infusion, there was another teen getting Skyrizi at the same time. the nurse said more kids starting to get Skyrizi there.

 

[my little penguin]

Woohoo!!!

 

[wrrywart]

Insurance is frustrating. In my experience there is nothing you can do to push insurance to make the approval faster. We were denied, then it went to appeal. For the appeal our ins sends it to a separate auditing process that is run by doctors and it was approved. When we had to change the dose of the same med the process started over. It's always a little scary worrying thst it will be denied. Keep having doctor appeal until it's approved. I hate that we have to jump through hoops. Both times it took 5 weeks from start until we got approval.

 

[my little penguin]

glimmer of hope our last prior authorization took 2 weeks total including initial expected denial and then approval after appeal.
but this was for the same med same Dose he has been on for 5-6 years now

 

[momsa]

Here's to encouraging people to call insurance companies, if you have the time. I recently called our insurance company to check on status, and they said they hadn't even received the request that Option Care said they put in. The wonderful nurse at my son's IBD office put the request in again. I followed up and found out they needed to set up a peer to peer. Letting the nurse know that moved things along too. Sometimes the insurance companies claim they contacted the doctor office for a peer to peer but the doctor never got a message. So I'm definitely of the opinion that making these calls can move things along.