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My insurance denied me getting my meds???

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Crohn's Disease
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Posted 9/11/2009 10:40 PM (GMT 0)
What right does Insurance companies have to denie someone getting the medication

they need??????????????????   I made some calls this morning to find out what the hold

up was on me starting on Cimzia.  I come to find out my insurance has denied me

getting it.  Has this ever happened to anyone else before??     I was busy at work and

didn't have a chance to call the doctors office but I will be calling first thing Monday

morning.  I guess doc has to appeal it, but what if they denie that?? devil

Posted 9/11/2009 10:49 PM (GMT 0)
Often the insurance company needs more documentation than the doctor provided when the med was prescribed. Also, some insurnace companies require a patient to try one of the older biologics before starting a newer one. My insurance denied my Simponi initially until my rheumy provided information that I had failed Remicade and Humira.

I think my various insurance companies all denied my biologics at first. Then when the doctors appealed, I was approved. I hope your Cimzia issue is approved without much further delay.
Posted 9/11/2009 11:28 PM (GMT 0)
Don't panic! It is insurance company policy to flat-out deny many claims, in the hope that you'll give up and go away. I've been denied innumerable times. Each time, I've called my insurance company to find out the reason for the denial. I've called my doctor's office and told them what the insurance people are saying (which is usually something like "wrong code"), and asked them to resubmit. Sometimes it takes a round of two of this. But the insurance company has always caved--every single time.

Make sure to get all the documentation you can. If they tell you that the diagnosis code is wrong, make sure to get them to tell you exactly what code was submitted--and what code it should be. NEVER yell or get angry with the insurance rep--it's been proven that they respond better to a polite but firm customer. Keep asking them what you'd need to do to resubmit the claim. Sometimes they'll even tell you the exact wording that your doctor's office needs to submit. Stay cool, calm, and collected, and remember that they do this to everybody, as a matter of policy, to try to discourage you and your doctor. With luck, they'll give in. Go for it!
Posted 9/11/2009 11:33 PM (GMT 0)
Mine wouldn't let me get my humira because I wasn't sick long enough. The thing is, nothing was helping, the bleeding wouldn't quit, and I literally would have wasted away. However, my doctor did appeal and basically fought with the insurance companies to get everything through. I did end up being able to get my medicine covered. Just keep trying...
Posted 9/12/2009 2:27 AM (GMT 0)
They just hope your doc won't bother to refile the paperwork. Some docs can't be bothered and will just have you take something else.

I had one doc that claimed he didn't have time to fight the insurance companies every time they refused a medication and why couldn't I just pay out of pocket. The prescription would have been $65/month full price but only $10/month with insurance. It took him 3 weeks to finally file and I was approved. I fired him after that.
Posted 9/12/2009 11:12 AM (GMT 0)
Cimzia is pretty expensive so I'm sure there are some serious guidelines for getting approval. I hope this doesn't shock you but...insurance companies only care about money...they really don't care about you or me.

I worked for an insurance company for awhile so just be aware that they may not be able to tell you the diagnosis code that was submitted on your claim or other specific information. It sounds like naw has had some luck with one insurance company but we weren't allowed to give that information at the one I worked for. They looked at it like...its your doctors job to give you a diagnosis, not a customer service rep (you would be surprised by how many people have no idea what their diagnosis is)...plus it prevents lawsuits (imagine they miscode it for cancer and I tell you have cancer...and you dont).

Anyway, what they WILL be able to tell you, no matter what, is what is wrong with the claim or why it was denied. You can then find out their appeals process and either appeal it yourself with information given to you by your doctor OR if you have a nice doc...they can appeal it for you. Most appeals get approved and even if it doesn't ...there is more than one level of appeals.

Hang in there!!
Posted 9/12/2009 4:50 PM (GMT 0)
Thank you everyone!! I'm sure my doctor won't have a problem to appeal it. I just have to call Monday
and make sure he is. lol I didn't realize this was so normal so I feel better now. lol
Posted 9/12/2009 7:52 PM (GMT 0)
Have your benefits administrator help also.
Posted 9/14/2009 6:14 AM (GMT 0)

LBJ said...
What right does Insurance companies have to denie someone getting the medication
they need??????????????????

The CEO of your insurance company needs a new LearJet. Somebody has got to pay for it, right?
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