Posted 10/15/2013 11:47 PM (GMT 0)
I was denied LINX by Horizon BCBS of New Jersey. After eight months of going through their appeals process, their paid hit men, Allmed Healthcare, denied me today. Supposedly it is over now.
Contrary to what you were probably expecting, this isn't a story about everything that transpired. This is a story about how a desperate company and its greedy hit men took me out.
LINX was denied as an investigational/experimental procedure. One would think that the external appeal company would address LINX versus Nissen, but that's not what Allmed did. Allmed apparently cannot argue logically against LINX, so on behalf of horizon they had to attack me.
Now, imagine from a logic perspective what you would have to do to deny LINX if you don't have a sound basis. All that's left is to attack the patient and try to prove that they don't need ANY procedure. That's exactly what Allmed did on horizon's behalf.
Let me list the tangential arguments used against me for your entertainment. Keep in mind this is supposed to be about LINX being experimental.
"Based on provided records and documentation, the patient has multiple issues that are contributing to his problems". I like how non-specific the wording is. It sounds like a fifth grader using "things" as objects because they don't know how to write.
1.) "has significant psychiatric comorbidities for which he has not been consistently treated". I have been prescribed Xanax for years because I am a senior project manager and have trouble sleeping at night during major projects.
2.) "is overweight, and efforts to lose weight or modify his lifestyle to improve reflux have not been documented". OK. My BMI is 27. I am 6'-2" and weigh 212 lbs today. According to my life insurance company, 211 lbs is normal. So yeah I'm 1 lb overweight. I eat organic food at every meal. My house's air is filtered with the best purifiers. I have two water distillers running constantly for pure water. I walk 45 minutes every night. I see a pastoral counselor at least bi-weekly for spiritual therapy. I use Stevia as sweetener and avoid sugar at all cost. I eat high fiber foods. I know the acid/alkalinity pH values of all foods that I eat and religiously avoid acidic foods. I have an app that keeps track of the water I drink, with nine glasses per day being my minimum. I could go on forever, but trust me I say that I am one of the most aggressive people whom you will ever meet when it comes to trying to improve my conditions through lifestyle and nutrition.
3.) "is a binge drinker". This is 100% false and a baseless accusation. At no time have I ever discussed excessive drinking with any doctor. It is possible that on questionnaires I have shown as much as 5-7 drinks per week, but calling me a binge drinker to attack me is pathetic and humiliating.
4.) "it seems there is a disconnect between the objective findings during the patient's evaluation and his symptoms". So in other words, a surgeon, a gastroenterologist, an ENT, my family physician, and a chiropractor that has x-rays showing the back and neck damage from yr
Ears of sleeping on piles of pillows, who are all waiting for me to have corrective surgery, are all wrong and have no idea what they're talking about. Keep in mind that two of my doctors graduated from Harvard. I have a great team assembled and it took great effort on my part. This was a very offensive statement to me.
5.) "at this time it is doubtful that any laparoscopic anti reflux procedure will improve his condition". Again, this is slanderous towards my doctors and has absolutely nothing to do with establishing LINX as correctly labeled as experimental.
6.) "The case for truly refractory reflux that could be solved by any type of anti reflux procedure has not been made. Medical necessity has not been shown at this time". Again, no relevance to LINX.
7.) "Per 2013 Guidelines of the American College of Gastroenterology, 'surgical therapy is generally not recommended in patients who do not respond to PPI therapy". This has no place in my analysis. I take Dexilant and it controls heartburn, but can't keep the contents of my stomach from coming out.
As you can see, I was attacked with fabricated, false, and misleading information, all while never addressing the experimental nature of LINX. Never in my life have I felt so violated and defenseless.
Does anyone know of any possible recourse?