Writing insurance appeal for meds. Any suggestions?

[My Butt Hurts]

So I got denied for a double dose of Humira, then I got denied for Cimzia.
My doctor is calling the medical director of the insurance company Monday morning, but he still wants me to fill out the appeal form and fax it over.
I have a lot of things I am going to write, but if anyone has anything brilliant to sway their minds, I would appreciate it.
I've got all of my personal information, but I'm lacking scientific facts.

I'm listing ALL of the medications that I have tried and have failed, personal weight loss/trips to the bathroom in my last flare, success with Humira in the beginning, keeping my fistula manageable since I've been on it. Also, the reasons I prefer not to take Remicade at this point.
I might even talk about crapping my pants in public. Not sure yet.
Any other suggestions?

 

[ladyB]

Is there a counsellor you have seen or if you talked to your doc about some of the emotional fallout one has with CD?
Maybe they could let the insurance co. know how important it is for you to have the meds your doc wants you on.

 

[My Butt Hurts]

Wow. Good tips.
ladyB - I'm pretty good with all of this emotionally, but it wouldn't hurt to mention what Crohn's can do to people - not just physically.
Mike - I am a union member, but we are on my husband's insurance. They are anti union big time. He will be talking to the head insurance guy at work tomorrow though.
Kim - state ins. comm. office. Never heard of it. Thanks.

Hey - could you just imagine if I walked into the office, Al Capone style and demanded that they sign my Humira prescription. Ha!
Hey - who's gonna make a "Surviving Crohn's Like A Gangstah" movie?

 

[My Butt Hurts]

Well, here's my letter. I don't love it, but it is what it is....

Appeal Request
Subscriber Name:
Membership #:
Patient Name:
Date: 10/01/2008


Have you ever crapped your pants in public? No? Then keep reading.

I have Crohn’s disease, and have been denied coverage for important medications by your company. I have tried sulfasalazine, asacol, pentasa, rowasa, librax, imuran, prednisone, ciprofloxacin, metronidizole, cortifoam, and probably others that I have forgotten. Some of these provided remission for a short while, but now I need something stronger.
After a bad flare last winter I was down to a 96 pound skeletal frame (5’8” female). I was using the bathroom 10-12 times a day, due to inflammation. My gastroenterologist put me on Humira, and within 6 days I started feeling relief. I was in the BEST remission since my original diagnosis, and managed to gain back 40 well needed pounds. That remission lasted 4 ½ months, but then I started slowly feeling some symptoms back again. I started losing weight again, and my doctor and I both thought that I should use a double dose of Humira, which by the way is approved for rheumatoid arthritis. I was denied that dose, so we thought that CImzia might help me instead of Humira. It is a similar medication to Humira, and used when other medications fail. Obviously other medications have failed me, but for some reason I was denied coverage for Cimzia too. My case is not mild or moderate, it is severe. Humira and Cimzia are for severe Crohn’s disease. I am in need of medication, yet I am caught in red tape without the one I need.
It’s more than just the weight I lose that is the problem here. Urgency to use the bathroom is a big problem for me, not to mention pain, bleeding, exhaustion, emotionally wondering every second when I will have to use the bathroom next, where is a bathroom, and if will I make it. I’m not healthy, and I need some medicinal help to be healthy. I HAVE insurance, how is this fair?
Crohn’s disease is one of the most difficult diseases to diagnose. Everyone’s symptoms are different, their reactions to foods are different, and most importantly their reactions to medications are different. My doctor, not my insurance company, knows what is best for my health, and he thinks that Humira is worth a try. I’m not sure how your company gets to dictate who gets to experience being well and who does not.
Me being well equals saving money for you in the long run. If Humira or Cimzia keeps me in remission, then I avoid surgery. Also, Humira is keeping my fistula manageable. I have already had surgery for a fistula, and since starting Humira, my current fistula has been kept dormant.
If you don’t know awful Crohn’s disease can be, please research it and then think about having it without the medication you need.
I look forward to a prompt and positive response to this appeal.

 

[mommy1st]

I think your letter is really good. Hopefully it will get their attention. I think more people need to take action against insurance companies. Good Luck.

 

[BWS1982]

Sorry, found two mistakes (grammatical and a personal). At the end, you said "If you don’t know awful Crohn’s disease can be", you missed the "how" before awful.

Up a bit, you said "and he thinks that Humira is worth a try" and you tried Humira, I think you mean Cimzia here, since you haven't tried it. I know you went for an increase in Humira, but trying it you've already done.

Just trying to help with that. I think your letter is to the point, but a bit brash. You are borderline condescending in a few spots, insinuating a lack of knowledge (though they lack it), and capitalizing some words that come off as almost sarcastic. YES, they deserve condescension, and much more (oh yeah), but I think it's best to play nice with these issues first, biting your tongue and making an "ally", not distancing yourself more. Just my opinion, I was VERY to the point and spoke of the severity in my disability appeal, and explained boldly how I CANNOT work, but didn't tell them about my thoughts on their knowledge of the disease for fear of making it harder and worse. Parts are great though, like making this a money issue, saying "hey, look, you want this medicine or a costly surgery" and explaining that your doctor knows better. I just think you can say all that you have said with some "sugar-coating" and have a better result is all, as painful as it is to sprinkle it on.

Maybe your doc sees no problem with appeals worded like that? I don't know, maybe it was just my take. ??

Just my 2 cents, good luck Butt.

 

[My Butt Hurts]

Benson - thanks for your response. It was POURING out this morning, so I didn't make it to the mailbox.
I changed the two mistakes, and changed the snotty "research it" sentence to
"Crohn’s disease can be an awful disease, think about having it without the medication you need."
I know that I am known for my sarcasm, but I wasn't trying to be sarcastic with my capitalized words. Those doesn't even sound sarcastic to me. I do that a LOT, when I am trying to put the emphasis on something. Ex. - Humira really did give me my BEST remission. Emphasis on the word best, see?

I think I used Mike's advice of "You get more action with a kind word and a gun, than with a kind word alone" - Al Capone rather than "You get more flies with honey..." hey, do you know the ending to that? For Crohn's I will change it.
You get more flies with honey than you do with frequent urgent bloody painful diarreah.

Also, my doc gave me no advice whatsoever on filling out the form. Well, except for he said fill it out and send it in.

Here's hoping.....

 

[BWS1982]

I'm well known for my sarcasm and twisted sense of humor as well, so I know what you mean. I dunno, just that I felt (in my own opinion) when I wrote mine, it was a time to sensor myself, but I guess I agree with all occasions where you capitalized words, it's not like you said "what do YOU know about this disease", that wouldn't be so great.

Mike, if I recall, didn't they cite something like "hasn't tried Remicade yet" for her? I'm kinda shocked since I thought that was more costly than the other 2.

 

[My Butt Hurts]

Denial for the Humira was because it isn't FDA approved in that dosage for Crohn's, only for Rheumatoid arthritis.
I haven't even gotten the denial letter for Cimzia yet, but the lady who read it on the phone to me said I hadn't tried enough other things yet, including Remicade.
If you do the math though, since Humira would be every other week and Remicade is every 8 weeks, so I think Remi IS actually cheaper looking at it that way.

 

[BWS1982]

Yeah, good point. "Hasn't tried enough other meds", yeah because you are denying them you dinks.

 

[My Butt Hurts]

I got a call today from the insurance company. They said that normally they would have 30 days to reply to my appeal, but they have deemed it a dire situation so it is now an expidited appeal, and I will hear the answer tomorrow. I don't know if my GI doc had anything to do with that or if it was just my "charming" letter, but hopefully it will be good news.
I was kind of bubbly on the phone, and after I hung up I thought I should have sounded more sick. Not that I'm not, but I certainly didn't sound it. And, he asked if he could reach me at work tomorrow. I told him we had meetings all day. I should have said "Oh, I don't know if I can even drag myself to work tomorrow. I'll try to be near the phone but I'll probably be in the bathroom. Just leave me a message."
Hey - here's a question, how many times have you been ON the phone with the drs office and had to hang up to run to the bathroom?? Me? I think 3.

 

[drew_wymore]

I never got off the phone while running to the bathroom, hey .. they need to hear how sick I am.

I'm sad I missed this thread, I would have started my letter with .. "Dear *********s" but then again that's just me.

 

[My Butt Hurts]

Well, let's just say Remi is $4,000 every 8 weeks.
Humira is more than $1,300 for 2 shots. If I'm taking the higher dose of 2 shots every other week, that would be over $5000, right? I don't know the cost of Cimzia.

I think I'm feeling a tiny bit better lately. It's hard to tell. Maybe I'll just stick with the Imuran, and I think my dose is going to be upped next week. I have to remember that I'm still on pred though. Crap - I just don't know!
Also, I'm going to look into what Mike said about "From what I recall from the NY state website, that is not a valid reason for denial. Not medically necessary, unproven or experimental; those were two examples I remember but "hasn't tried remicade yet" is utter bs."
I'm not losing any weight right now, and my worst symptom is urgency, but it seems to hit me at luckily good times. Poop is almost normal (soft serve) just a bit more frequent. I can live for another month or 2 and wait and see, then try Remi I guess. I almost want to try stopping the Humira just to see if what the Imuran is doing. I mean, if the Humira was quitting anyways, why stay on it? But who knows if it is helping even a little?

 

[My Butt Hurts]

I can't belive that with an insurance company though. Maybe with the rest of life, but not that.
Seriously, I don't know why I'm so against Remicade, it could very well give me a great remission for years. I guess it's just the creepy mouse protien and the breathing reactions that scare me.
OH, by the way - I had a mouse visit my classroom over the weekend! Got into my goldfish crackers. I got that and the tiny poops cleaned up on Monday, it was caught on a sticky trap on Wednesday. Apparently it has a friend, because I have found poops in the same spot on Thursday and Friday even though there is no food there anymore. As soon as I saw that dead mousie on the trap I thought of Remicade. Eeek!

 

[My Butt Hurts]

So I officially got the insurance approval # for Remicade. Yippety-skip, the one I didn't want to try. I've been dicked around by this insurance company so many times in the past 2 weeks I called them back just to double check the co-pay. I thought it might be hundreds of dollars, but it's only 20 bucks. My GI office was calling today to make the appointment for me, and I guess I'll know soon when I go for the first time. At least it's in a hospital so if I have a reaction they MIGHT know what to do. Oh God Colt, don't tell me they won't - let me just pretend.

I really wonder if I would have been approved for either of the others if I was still on Blue Choice. We were made to switch to Preferred Care in January.
That was a WHOLE other story. We didn't get our new cards for the whole month of January, and my husband's work told us to still give our old cards. I had like 9 appointments in January at all different places, and they (not me) are still trying to straighten out the bills. Ridiculous.

 

[My Butt Hurts]

My GI office was calling today to make the appointment for me, and I guess I'll know soon when I go for the first time.

Really Pen?

 

[My Butt Hurts]

It's official. I'm approved for Remicade, I have to wait 30 days after my last Humira injection, my appointment is Monday November 10th. Yippity-skip. I hope it frikin works.

 

[drew_wymore]

Yaaaaaaah. I should but dont jinx your self, think positive.

Miiiiiiiiiighty Mouse cometh.