So Here It Is!

So....this is it.  This is what our second tier appeal to the health insurance coverage hinges on.  The irony of the entire situation is that Baylee had "surgery" yesterday.  Aspirations (the withdrawal of fluid from her joints) and the injection of steroids directly into the problem areas.  They don't usually do more than 4 joints at a time, yesterday they did 6.  She had a team of 7 doctors and nurses.  United won't pay for her medication or treatment....but they will pay for that.  Go figure!  Wish us luck!!!

March 26, 2012

United Healthcare

Attn:  Appeals Department

PO Box 30432

Salt Lake City UT 84130-0432

RE:     Subscriber ID:            908007314                            Group/Contract:        192961

            Patient:                    Baylee A. Morgan                Date of Birth:            06/11/2001

            Diagnosis Code:       714.32                                    Procedure Code:      J1745

            Date of Service:        01/11/12; 02/07/12  

To Whom It May Concern:

I am appealing the denial of claims submitted from CH WUSM Ped Diagnostic on dates of service 01/11/12 and 02/07/12 for Baylee Morgan for the following reasons:

1.    Good Faith:  Treatment was pursued based on assurances by United Healthcare Employees that the procedure and diagnosis were covered.

2.    Covered Under Previous Insurance Plans

3.    Medical Necessity: A proven history of the failure of other TNF inhibitors.

2012 Coverage - Good Faith

We switched insurance to United Healthcare as of January 1, 2012.  Sue Price, the insurance coordinator with Rheumatology department at St. Louis Children’s Hospital called to authorize her treatment and received verification of coverage.

Baylee received her first Remicade infusion on January 11, 2012.   We received a denial for the treatment at the end of January.

The denial listed diagnosis code 364.01 (Primary Iridocyclitis) which is the diagnosis code for Uveitis and Iritis.  I called and spoke with Sue Price, who agreed that the code should have been 714.32 (Juvenile Idiopathic Arthritis), and that they had already begun an appeal process and were conducting a peer to peer review with United Healthcare.  Sue said it is not uncommon to receive denials at the beginning of the calendar year, and to go ahead with the next treatment as it was likely just a diagnosis code error.

Baylee had her second Remicade treatment on February 7, 2012.  We received our denial of appeal near the end of February.

As part of my process of appeal, I called several times, speaking to several different employees of United Healthcare.  Following is a chart of dates, individuals and conversation notes.  All phone calls were initiated by me.

Date	Dept./Employee	Conversation
February 24, 2012	Appeals	Instructed me on appeals process.  I asked what Remicade was approved to treat and was transferred to the UHC pharmacist (Chris), who said he didn’t know why I was transferred to him and he couldn’t help me.
February 24, 2012	Member Services / Vanessa	Verified diagnosis code 714.32 and procedure code were covered.  Confirmed both codes were covered.  Specifically asked if JRA was excluded and was told it was not excluded, that Remicade was APPROVED treatment for JRA.
February 24, 2012	Member Services / Barb	Explained issue, said I had additional questions.  *Disconnected*
February 24, 2012	Member Services / Stephanie	According to plan documents, Remicade is a COVERED procedure for treatment of JRA.  Verified code 714.32 was used for billing.  She said she didn’t know why it was denied.  Stephanie talked to her supervisor who suggested I be transferred to Rapid Resolution Claim Center to have claim fixed.
February 24, 2012	Rapid Resolution Claims Dept / Kira	Confirmed appropriate billing code and procedure code.  Kira said claim had to be processed manually, not automatically.  She flagged both claims, said they would both be paid and that new EOB’s would be issued within 10 business day.  She said she also flagged the account so we wouldn’t have any issues the rest of the year.

Both claims were denied again on February 27, 2012.

Date	Dept./Employee	Conversation
February 28, 2012	Rapid Resolution Claims Center / Karina	Told her I was told claims were covered and asked for explanation of denial.  She said the notes said it was not approved.  Asked her for a list of Remicade approved treatments, she said it would take 5 business days to figure out how to do that.  I asked to speak to a supervisor because the information was necessary for appeal.  She said there were no supervisors available and one would call me back in 24-48 hours.
February 28, 2012	Member Services / Susie	Asked for copy of what Remicade was approved treatment for.  She was unable to find a way to get me the information.  She said according to plan documents, Remicade was APPROVED treatment for JRA.  Suggested a second level appeal.
March 1, 2012	Member Services / Unknown Male	Said there is no such thing as a Summary Plan Document.  I asked for information on how they knew what was covered he said it was all programmed in the computer.
March 1, 2012	Member Services / Ramona	Asked for supervisor from Rapid Resolution Claims center because they never returned my call.
March 1, 2012	Rapid Resolution Claims Center / Sharina	Sharina said we could get a copy of our Summary Plan Document from Aon or benefitsnow website for Henry Schein.  Sharina said the procedure is a COVERED procedure, but not for all diagnosis codes.   Sharina confirmed that procedure code J1745 is approved to treat 714.32.  Gave me the phone number for Claim Coordination Dept to verify.
March 1, 2012	Claim Coordination Dept / Lisa	Verified procedure code J1745 was approved to treat 714.32.  Lisa said notification is not required and to re-verify benefits through Member Services.  Transferred.
March 1, 2012	Member Services / Mitch	Verified J2745 is APPROVED to treat 714.32.  Gave following benefit information: Outpatient covered at 85% Office Visit covered at Office copay amt. Out of Network covered at 70 %

Based on information provided from United Healthcare, we continued forward with Baylee’s treatment on March 13, 2012.

We ask you to reconsider the denial of payment for the Remicade treatment on Good Faith effort on our part to verify coverage.

Covered Under Previous Insurance Plans

Baylee received Remicade treatments for almost a year and half with no opposition from previous insurance companies.

Date	Insurance Carrier	Status
July 7, 2010	Intermountain Healthcare	Covered / Paid
July 20, 2010	Intermountain Healthcare	Covered / Paid
August 17, 2010	Intermountain Healthcare	Covered / Paid
October 16, 2010	Intermountain Healthcare	Covered / Paid
November 20, 2010	Intermountain Healthcare	Covered / Paid
December 18, 2010	Intermountain Healthcare	Covered / Paid
January 15, 2011	Intermountain Healthcare	Covered / Paid
February 12, 2011	Intermountain Healthcare	Covered / Paid
March 12, 2011	Intermountain Healthcare	Covered / Paid
April 9, 2011	Intermountain Healthcare	Covered / Paid
May 21, 2011	Intermountain Healthcare	Covered / Paid
June 18, 2011	Intermountain Healthcare	Covered / Paid
July 16, 2011	Intermountain Healthcare	Covered / Paid
September 1, 2011	Cigna	Covered / Paid
September 29, 2011	Cigna	Covered / Paid
October 26, 2011	Cigna	Covered / Paid
November 22, 2011	Cigna	Covered / Paid
December 20, 2011	Cigna	Covered / Paid
January 11, 2012	United Healthcare	Denied / Appealed
February 7, 2012	United Healthcare	Denied / Appealed
March 13, 2012	United Healthcare	Denied March 23, 2012

Medical History

In May of 2003 Baylee Morgan was recovering from pneumonia, when she suffered a fall down a 2-3 stairs.  Her knee became swollen and she had difficulty walking.  Over a period of days, she regressed from a busy, active toddler to a child who needed assistance to walk, then becoming unable to walk at all.  After a series of tests, her condition was still unknown.  We were sent to an orthopedic surgeon to check for any abnormalities in her knee. 

On June 11, 2003, the orthopedic surgeon found what he termed a “tumor”, or unknown mass within her knee joint.  He was able to get us in to Dr. Lor Randall, an orthopedic oncologist within a period of weeks.  Upon initial examination, he felt biopsies of the affected areas were necessary, and felt certain it was likely cancer.

When the biopsy results came back, there was no sign of cancer, but all areas biopsied showed severe inflammation.  We discussed the possibility of arthritis, but Dr. Randall deferred to Dr. John Bohnsack, Pediatric Rheumatologist, for an assessment

We met with Dr. Bohnsack in August 2003, where he confirmed diagnosis of Juvenile Rheumatoid Arthritis (JRA).  Dr. Bohnsack noted that several joints were involved (toes, ankles, knee and elbow), and immediately started her on an NSAID, Naproxen

At her six week follow up examination, the Naproxen, while helping slightly, had not done enough to reduce the pressure of the inflammation on Baylee’s joints.  In September 2003, Baylee began a weekly subcutaneous injection of Methotrexate.

The Methotrexate showed positive results, and while it was adjusted from time to time to accommodate her growth and progression of her disease, was considered all that was necessary for treatment at the time. 

At age 3 ½ (approximately) she was diagnosed with Uveitis, and later Iritis.  Baylee’s eye conditions were treated separately with an Ophthalmologist.

In the first few years of the Methotrexate treatment, Baylee entered remission of her disease, but upon discontinuation of the medication, the JRA returned.  Shortly after the return of the JRA, there was a shortage of injectable Methotrexate and Baylee was switched to oral Methotrexate.  Baylee was more resistant to the oral version of the drug, and began to physically regress.

Upon renewed availability of the injectable form of Methotrexate, and an increase in dosage to accommodate her growth, Baylee once again began to show improvement.

In July of 2005, at a regular examination from Dr. Bohnsack, Baylee showed persistent inflammation in her ankles, knee, elbow, wrist and toe.  The decision was made to add Enbrel (Enteracept) to her regimen.

Baylee’s arthritis was controlled on Enbrel, but she never did enter into remission. She was doing well enough to have the Enbrel discontinued in March of 2008.

In June of 2008, because of active arthritis in 2 joints and active arthritis, she began using Humira (Adalimumab) in conjunction with her Methotrexate.  In order to help control her inflammation, she also began taking Meloxicam.

Baylee remained on Humira and Methotrexate until June of 2010.  The Meloxicam had been discontinued because of abnormal blood tests.

After a flare up of both her arthritis and uveitis, Dr. Bohnsack consulted with Dr. Albert Vitale and together, they made the decision to start her on Remicade. 

Remicade was chosen in part because of the ability to adjust it according to the activity of her disease.

Baylee received Remicade treatment, covered under Intermountain Healthcare, until July 2011 when our family relocated to Missouri.

Upon our arrival in Missouri, we consulted with new physicians at St. Louis Children’s Hospital.  Dr. Andrew White, Rheumatologist, agreed with the previously prescribed treatment and continued the Remicade in combination with Methotrexate. 

Baylee’s treatment continued uninterrupted covered under insurance (through Cigna) until December of 2011.

I have included copies of Dr. John Bohnsack's examination notes and notes from the Department of Rheumatology at St. Louis Children’s Hospital (which were already submitted).

I ask you to consider appeal on the basis of Medical Necessity because through her medical history we have used the other two TNF inhibitors approved by the FDA without long term positive results.

After thorough research, the majority of insurance companies initially do not cover Remicade unless it can be proven that other TNF inhibitors have failed to control the disease, at which point it is covered.

I believe we followed standard treatment protocol for Baylee’s Juvenile Rheumatoid Arthritis, and throughout the course of treatment exhausted other stepped forms of treatments.  The course of treatment for Baylee was not considered lightly.  Several doctors who are specialists in their fields and in multiple locations (Primary Children’s Medical Center and St. Louis Children’s Hospital) were consulted and came to agreement that Remicade was the appropriate next step in her treatment.

I would respectfully request you approve the Remicade treatment to manage Baylee’s Juvenile Rheumatoid Arthritis and honor the health coverage and benefits as outlined by multiple representatives of United Healthcare.  Treatment was only continued on the basis of information provided, a history of coverage through other carriers and most importantly, the medical necessity of treatment to the long term care and quality of life for Baylee.

I appreciate your consideration.

Sincerely,

Wendy Morgan

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