I was given an infusion medication twice in 2018 and twice in 2019. It had to be pre-authorized. I do not remember how I learned this but I learned that the existing diagnosis wouldn’t be covered, but a different diagnosis I have would be. I told my doctor this, that he had to change the primary diagnosis to have it covered. Unbeknownst to me, he didn’t change it. The infusion claims was covered one month, and the other time it was approved initially but after the company audited their approvals they reversed it saying it was experimental. I am working on an appeal now.
How do I make them cover this based on the fact that they covered it in the previous month, without having them say “oh we shouldn’t have covered that one either, now you owe us $70,000 instead of $35k”?
Can I furnish proof that the original claim diagnosis is a covered diagnosis for treatment with this medication for multiple other private healthcare plans? If Cigna, Aetna, BCBS all say this med can be used to treat original diagnosis A, after trials of other treatments have failed, will that sway them?
I think the original doctor retired. How do I get a letter of medical necessity?
The clinic that did the treatment isn’t helping me. They said I’m on my own. I feel like if I told the physician this won’t be covered unless you modify the diagnosis and he didn’t modify it, that shouldn’t be my responsibility. But how do I get the law and the policy of American healthcare on my side in that? Is there a governing body over hospitals that would have any weight on them about not making this my responsibility? I don’t have $35k and if I did, I don’t think I should pay them when it was their doctor that ignored what I said the pre-authorization required him to do. Unfortunately my proof of that is gone because this was so long ago. I feel like they delay things like this on purpose because it’s harder to prove what really happened. Idk maybe I’m jaded.
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I was given an infusion medication twice in 2018 and twice in 2019. It had to be pre-authorized. I do not remember how I learned this but I learned that the existing diagnosis wouldn’t be covered, but a different diagnosis I have would be. I told my doctor this, that he had to change the primary diagnosis to have it covered. Unbeknownst to me, he didn’t change it. The infusion claims was covered one month, and the other time it was approved initially but after the company audited their approvals they reversed it saying it was experimental. I am working on an appeal now. How do I make them cover this based on the fact that they covered it in the previous month, without having them say “oh we shouldn’t have covered that one either, now you owe us $70,000 instead of $35k”? Can I furnish proof that the original claim diagnosis is a covered diagnosis for treatment with this medication for multiple other private healthcare plans? If Cigna, Aetna, BCBS all say this med can be used to treat original diagnosis A, after trials of other treatments have failed, will that sway them? I think the original doctor retired. How do I get a letter of medical necessity? The clinic that did the treatment isn’t helping me. They said I’m on my own. I feel like if I told the physician this won’t be covered unless you modify the diagnosis and he didn’t modify it, that shouldn’t be my responsibility. But how do I get the law and the policy of American healthcare on my side in that? Is there a governing body over hospitals that would have any weight on them about not making this my responsibility? I don’t have $35k and if I did, I don’t think I should pay them when it was their doctor that ignored what I said the pre-authorization required him to do. Unfortunately my proof of that is gone because this was so long ago. I feel like they delay things like this on purpose because it’s harder to prove what really happened. Idk maybe I’m jaded.
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