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United Health Care & Remicade?

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Ulcerative Colitis
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Posted 6/16/2010 4:03 PM (GMT 0)
I just got word from my doctor's office that United Health Care has denied my claim for Remicade and now we have to appeal. Lovely. I was just wondering if anyone else had the same issue with insurance and how difficult the appeal process was?

In the mean time, I might try to eek my prednisone dose down a little more. I'm so angry. I've been on pred. for almost 4 months now...
Posted 6/16/2010 8:09 PM (GMT 0)
Did they say why you were refused?

My doctor is about to start the process of applying for remicade for me (after my TB and blood tests) and I have United Healthcare. Now I'm really getting worried since this insurance sort of sucks as far as copays on my medicines as it is.
Posted 6/16/2010 10:36 PM (GMT 0)
I have not spoken to them directly, but when I do I'll let you know what they say.
Posted 6/16/2010 10:57 PM (GMT 0)
I'd appreciate that. They have to give you some sort of valid reason since judging by your meds, you've exhausted all the alternatives other than surgery. I've been flaring since around the same time as you Dec '09 (off and on--more on than off) and I've tried everything and nothing is working anymore. I'm back on 40mg of Prednisone for the past week and I should be a lot better by now and I'm not.
Posted 6/17/2010 12:24 AM (GMT 0)
I have done appeals before but only after the procedure was done. Preapprovals involving health threating issues(like yours) go a lot faster but you need your doctors help. Lots depends on the state you live in and the policy you have.State law` controls the process. Usually there is a second appeal in house at the insurance company then another by an outside party usually a state insurance commission. You need to talk to your doctor and the person in your office that handles this process. He has to pressure them that it is a expedited appeal because it threatens your health. In my experience talking on the phone with the insurance company is a waste. Do everything in writing and check your policy for the procedure. An experienced person in your doctors office is worth their weight in gold. The customer service and appeals people at the insurance company will give you the wrong info and even lie. They are paid to deny claims. Do not give up. Often they just sandbag you then cave.
Posted 6/17/2010 2:29 AM (GMT 0)
Thank you for the info AZYooper! The assistant at the doctor's office said she was going to put together my medical records and a letter from my doctor and that I needed to write a letter on my own behalf as well. Before I do that I want to speak to the insurance company to make sure I am including all of the information they require so that it doesn't get bounced back for missing information. I think you could be right they may very well be sand-bagging me. I have been an expensive customer this year!
Posted 6/17/2010 9:44 PM (GMT 0)
The UHC rep. couldn't tell me why it wasn't being covered. She said my policy has coverage for infusion medications. However, when she punched in Remicade the diagnosis code came up as Rheumatoid Arthritis. So, I am wondering if that's the problem. They don't have Remicade preapproved in their system for Ulcerative Colitis. She told me the review process will take 30 days unless I can get them to accept it as an urgent request. I can't imagine being stuck on prednisone for another two months... I am feeling pretty sad. :o(
Posted 6/18/2010 12:02 AM (GMT 0)
At least with my insurance an expedited appeal requires that you have urgently needed services that you have not yet received that you requested precertifcation for which was denied. You need a doctors letter certifying that waiting for a standard appeal could negatively effect your medical condition. This letter must include supporting documentation like previous/current treatments and history.

Really seems like you fit an expedited appeal and your doctor most probably does these regularly. Total time in Arizona for the 3 legally required expedited appeals is 1 day for informal, 3 days for level 2 and 2 days for the independent appeal. So it can be pretty fast. You need to talk to your doctors office to make sure they are on board.

They may just make you jump through the first hoop which could take only one day.

Look through your policy papers and the insurance companies web site for their procedure, what to send and where. They should have sent a denial in writing to your doctor and you for the preapproval. This should have had instructions on appeals and should have a case number. The telephone customer service people for my company are idiots and the whole thing is not worth getting worked up over. Follow the process in writing and they follow the law.
Posted 6/29/2010 9:18 PM (GMT 0)
Turns out the Prescription Solutions people aren't exactly the crispiest crackers in the package... they were trying to bill my prescription coverage instead of my medical insurance or some such. So, they are finally shipping out my Remicade! Now let's hope after all this waiting it works!

Must... get... off... pred... /twitch
Posted 6/29/2010 10:07 PM (GMT 0)

gdfairy said...
I'd appreciate that. They have to give you some sort of valid reason since judging by your meds, you've exhausted all the alternatives other than surgery. I've been flaring since around the same time as you Dec '09 (off and on--more on than off) and I've tried everything and nothing is working anymore. I'm back on 40mg of Prednisone for the past week and I should be a lot better by now and I'm not.

Sorry to hear you're doing so poorly. You sound exactly how I am. I've been dealign with this flare up since dec/jan and been on prednisone since Jan/Feb and I just want off. I am on 6mp now. Have you been pushed toward 6mp before Remicade? I hope the 6mp helps. I had to go back up to 40mg but I am down to 20mg again and worried I will start getting worse. I can't wait to be off this stuff, I feel so fat and gross!! I was on 40mg for ~2 weeks in order to get back to "normal". I thought I would NEVER get better this most recent relapse. After a week at 40mg, with NO improvement, I was seriously feeling like NOTHING would help! It was a terrible feeling. Keep thinking positive and don't rush to get off the higher dose until things improve.

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