Nine Months....and GAINING

Wow!  I know it's been a while.  The world has been somewhat a topsy, turvy place lately.  I'll give everyone a short, short version of events and then I'll get into the body of my post.

In case you hadn't heard.  We won our legal battle with United Healthcare.  It was touch and go for a while and I couldn't wrap my brain about how to pay for future care and the $21,000 medical bill created by just the first 3 months of this year.  However, Heavenly Father saw fit to intervene and softened some hearts that had the power to fix this for us.  Our bills have been paid (although United alternates...still...in between sending letters of rejection and letters of apology), the hospital still likes us and although we didn't share this with United (it was need to know...AND THEY DIDN'T NEED TO KNOW), Baylee has switched medications and we are in the scary part of treatment where we wait and watch to see how her body reacts.  Also adding to the fun, her new medication may or may not treat her eye condition (for more information on that, I happily direct you to http://www.pinkburstproject.org).  So we wait and we watch and hope and pray that if the medication doesn't work, we catch it before permanent damage is done.

Noah has turned 12, received the priesthood and was made a Deacon (for all of my non-LDS friends, message me and I will be happy to share more on what that means) and happily gets ready for church EARLY on Sunday's because he loves the privelege of passing the sacrament.  He is definitely 12 and girls are on the radar.  He asked me the other day who Kate Middleton was.  I explained she was married to Prince William and asked why he wanted to know.  He said she keeps popping up on Yahoo!.  I said oh.  I don't think he knew I was listening (although I have mercilessly teased him about it since), but I heard him softly say, "I love Yahoo!."  Love it!

Caleb just turned 7....making me feel very, very old.  Next year when he turns 8, I may have to have plastic surgery because I will be in so much denial about how old all of my babies have gotten.  He was concerned that he needed to shave for his birthday....but I told him he was good.  He is as loud and adventurous as ever....and if I can keep he and Noah from fighting over anything electronic, I would be amazed!  They also share a room now, and when they aren't getting along, they lock each other out and invariably one of them sleeps in the hall.

Savannah is 14.  I hate 1 Direction.  It is Savannah's fault I hate 1 Direction because that is all she ever talks about....no....that isn't fair.  She also talks about her friends that like 1 Direction.  (**Side note:  all of my cute pinterest friends...stop posting 1 Direction on pinterest....you're messing with my page!  :))  When she isn't bothering me about 1 Direction, she is studying, hanging out with friends and pestering her teachers about how she can start taking classes this summer so she can graduation 1-2 years early because she really, really wants her Bachelors Degree early.  If any of my children can do it, she can.  She attend the high school here (she is in the 8th grade) for math, and was invited to participate on the High School Math Team for a competition.  Although she didn't place....I still think it's pretty awesome that she was asked to be on the team.

Felix is working and travelling.  And working and travelling.  And when he isn't working and travelling, he is travelling and working.  He has to spend quite a bit of time in Wisconsin for the next few months, so as soon as school is out, we are going to be groupies and start following him on the road!

Me?  I've been keeping it all together, getting new renters, finishing my Personal Progress, driving to and from the hospital and quite frankly....asking Heavenly Father lots and lots of questions.

So...PHEW!  That wasn't as short as I wanted it to be....but hey, there has been a lot going on and I have left a TON out!  But given the sheer insanity of the last few months, I just have to get this out.

When we made the decision to come to Missouri, we prayed, we fasted and knew that this was what we were supposed to do.  BUT....we were coming for "The Job".  "The Job" is what pays the bills and  hey, people work for money not fun (and if anyone tells you different....they're lying!).  Well, since Felix wanted to stay employed and I wanted to be able to pay bills, we just needed Heavenly Father's blessing to come and we received it.  Soooooo, we came to Missouri for "The Job".

However....little did we know (and by 'we', I mean me), how much more was in store for us.  Moving was not JUST for "The Job"....it was for me and my family....because we needed to stretch and grow.

"THE JOB"
Let's talk about "The Job" first.  Oooohhh, so many promises were made to get us here.  Felix wasn't going to travel.  His work schedule would normalize and he was going to have so much more time for the family.  You can see where this is going...right?  Well....he is gone more now than ever before.  Sigh.  We miss him.

"THE JOB" Helped Us Gain
But what have we gained?  Oh my...we appreciate each other SO much more than ever  before.  We make the moments count (instead of counting the moments).  We could have all the time in the world, but if we didn't use it, it wouldn't matter.  It matters....it matters to us!  Time with each other...exploring, talking, laughing, learning....we may not have a ton of time together, but the time we do have his richly filled with love and enjoyment!

"SCHOOL"
Let's talk about "School" now.  "School" has been rough.  Savannah was threatened, Noah was ostracized, the school ignored Baylee's 504 (her disability documentation), and Caleb was beat up and emotionally abused until it physically took a toll.  "School" was very, very scary there for a while.  But I would like to point out....it WAS!  What have we gained?

"SCHOOL" Helped Us Gain
Yeah, I give snippets on Facebook.  And most everyone knows my funny little Mormon kids go to a Lutheran school....and let me just share....WHAT A BLESSING it has been.  The kids are happy, well-adjusted (for my kids) and learning!  They come home happy, keep their grades up (mostly), and look forward to attending.  We have learned that being "Mormon" or "Lutheran" doesn't mean you are good or bad....that is up to the individual and the choices they make.  My children who had thus far grown up in a very sheltered Mormon environment have learned to be comfortable with their faith....and it is their faith.  Even Caleb has learned to pray for guidance and direction while he is learning Lutheran doctrine at school and Mormon doctrine at home.  We have gained many opportunities to discuss faith, and how faith doesn't belong to one religion or another, it's a personal thing.  We have gained opportunities to explain that people who do not believe as we do, or who make choices that are different than our are not 'bad', simply different...and that most importantly, it is not our place to judge.  Our job is to love.  And we are learning to do that whole heartedly (all of the time...with other people....it's a little harder with family :))

"CHURCH"
Church and the Gospel are 2 different things.  Did you know that?  Did you know that while the Gospel is true, people still have free agency and are able to choose actions for themselves.  This means that people have to learn right and wrong for themselves.  They have to learn good and evil for themselves.  Which can sometimes cause immense sadness, for themselves and others.

Can you tell I've been under stress lately?  That I've dealt with some things inside the church that took me by surprise?  Yeah.  And no....I'm not going to discuss.  Let's just say that my heart still hurts.  Sometimes I'm still surprised by the things that have transpired.  Sometimes I wonder what the heck happened and how did I get here.

"CHURCH" Has Given Me
I had a testimony before I came.  I did.  I trusted Heavenly Father.  Although, I am still me and love to question (even after I received answer....I'm the girl that says, "Are you sure?"), I trusted that Heavenly Father would answer my prayers, guide and direct me and then let me make my own choices (even if it was different than His will).

So what has this all gotten me.  My testimony is now made of stone.  I know who is in charge (and no, it isn't me).  I know that MY prayers are heard and answered by a loving Father.  I know that He knows who I am.  I know what it feels like to make stand.  I know what it feels like to stand alone (although I always feel funny saying that because I know I am never alone).  I know what it means to plead for understanding, patience and charity.   I know what it means to beg for forgiveness for my failings. I know what it means to have to separate my thoughts from the whispering of the Spirit.  I know what it is to feel peace in the midst of a storm.  I know that I will never "be enough" for anyone or anything...but I do know that as long as I am trying to do what is right, my shortcomings will be made up through the Savior's Atonement.  I suppose I can easily sum things up with 2 words....I KNOW.  I cannot deny the gentle, yet sure answers I have been given.

So...the adventure lives on...right?  Yeah....it lives on....but now, I'm gaining on it!

Lessons Learned
1.  There are so many...where to I start?
2.  I am lucky to be me.
3.  Because I have been blessed with amazing angels called friends.
4.  I am blessed with guardians called my family
5.  I am blessed.

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

Attachments

10 Business Days

So.....life has been so busy lately....the adventures never end....but this one is too perplexing not to share.  And children....ask Sears, Hollywood Video or any other place of business what happens when you mess with me.  Although....this isn't retail....perhaps I am expanding my horizons.

Many of you know, but some of my new friends may not, that we have had a series of adventures in the medical realm throughout this adventure known as life.  One of the greatest (and by greatest I mean time consuming.....because our trials are relative, based on what we need to learn) is Baylee's plate of adventures.

Among a host of things neatly piled on her plate of life, are arthritis, uveitis, iritis, neuropathy, erythromylalgia....yada, yada, yada, yada (and no I didn't list them all, I have to do that often enough on medical and insurance form, I most certainly don't want to list them in this forum!).

As we have gone through the different phases of Baylee's health, we have tried different treatments, therapies, medications....blah, blah, blah.  But in order to put things in perspective, I need to give a little background so you can understand why I am so wound up.

Diagnosis with Arthritis at age 2.  Anti-inflammatory's are the first step.  When they don't work, you move to Methotrexate.  When that stops working you add Enbrel/Humira or a cocktail of other medications that help balance the body attacking it's own cells.  We have done them all.

 Diagnosis with Uveitis at age 3.  This is eye inflammation, common in girls with Juvenile Rheumatoid Arthritis.  This is what spurred us on towards "cocktail medicine".

Diagnosis with Iritis at age 4.  This is worse eye inflammation, not so common.  But this is what spurred us on towards stronger "cocktail medicine".

All-in-all everything we have done medically is to keep Baylee walking and seeing.  That's it.  So as we have moved forward, things are stable, not stable, stable....that's just kind of how it works.  (For information on how uveitis and iritis works....this is our favorite (and only) charitable organization that is able to bring national attention to this disease  www.pinkburstproject.org)  And as we continue to fight these disease, and Baylee grows, we have to adjust medication.

Eventually....the medication just stopped working.  Time for a new cocktail.  And as expensive as her medications have been....oh man.....that was nothin'!

In June of 2010, we began Remicade treatments.  Intravenous therapy....and for any of my friends who have had, or have had a loved one with cancer, please forgive the comparison...but it is the closest thing we have.  Basically it is chemo.  But it is chemo with no end.  She started at therapy every 2 weeks, then every 4 week, then every 6 weeks, then every 8 weeks (which was too far apart for her body to stay stable), then every 6 weeks, then every 4 weeks....you get the idea.

For reference, it took a solid year before we were able to stabilize her eyes and take a step back from the threat of blindness.

In the mean time, we got this crazy idea to move to a new state....blah, blah, blah.  Once we got here, we had to get into new doctors, have the talk to her old doctors and get everyone to agree on the same therapy.  SUPER FUN!!!!

But, thanks to our incredible medical professionals from Utah, and their justification, Baylee's therapies have continued.  Some adjustments (because it has been difficult to keep her stable).  And because life is life.....we have switched insurance carriers.....TWICE!

So....out of the blue in January, we receive notification from our new insurance that Remicade is not covered.  It is considered an experimental treatment.  WHAT?????  They referenced her iritis/uveitis on the rejection letter and I wondered if that is why it was denied.

I call the doctors office insurance specialist...she says it happens all of the time....especially in January.  Happens all of the time, they have already prepared the appeal, and the doctor has already done the peer-to-peer review with the insurance carrier doctor....and to go ahead and do her next treatment in February.  At $7,000 a pop....why not?

So we do the February treatment and the doctor and I both receive rejections to the appeal.  And the doctors office gives me these options:
1.  Fill out the paperwork for their program to have the manufacturer pay for the medication (where income is not a factor....yeah, right)
2.  File a parental appeal.
3.  Pay the $7,000 a month.

So I call the appeals department at the insurance company, which proceeds to tell me, they will only deal with me in writing.  I ask one simple question.  What diseases is Remicade approved to treat?  She can't tell me that.  She is in the appeals department, she doesn't know about any of that.  But she can transfer me to a pharmacist who can help me with that.

So I talk to the pharmacist.  And he says....why did she send you to me?  I don't know anything about claims and coverage....I just am the specialist for what the drugs treat and the different therapies.  Yeah, I know.  It totally wasn't him....it was the appeals lady who just didn't want to talk to me anymore.

So I call the insurance company again to ask what diseases Remicade is approved to treat.  The lady I talked to  said Remicade is approved to treat Juvenile Rheumatoid Arthritis, but it is not approved for uveitis and iritis.

So I call the doctors office insurance lady back to ask again if it was denied because of the billing code.  She said that all of the correct codes were referenced, but told me who to ask at the insurance company and that we would talk again on Monday.

So I call the insurance company back.  I explain that I think everything was denied because of an incorrect diagnosis code.  And *CLICK*, she hung up on me.  I guess work was optional for her today.

So I call back again.  I talk to the Medical coverage peoples.  She was great.  I explained the entire thing, and she said it should be covered.  She asked if she could put me on hold so she could talk with her supervisor.  Then she and her supervisor came back and said they can't figure out why the claims keep getting denied.  Remicade is approved for the treatment of Juvenile Rheumatoid Arthritis. However, it is NOT approved for uveitis and iritis.  Well, that is what they said earlier.  But this time, they transferred me to the Rapid Claims Resolution Center, so that I could find out what was being denied so that I knew how to prepare my appeal.

FINALLY!  That is what I needed!  How on earth could I fight the insurance beast if I didn't know which part of it I was fighting.

Soooooooo, I talk to Kira in the Rapid Claims Resolution Center.  I give her all of our information.  And for the 457th time today, I tell our sad, sad story.  She pulls up the claims and says, "Oh, I see what the problem is.  It has the correct code.  It has the other codes as well.  This type of claim can't be processed through the system automatically.  It is supposed to be flagged and processed manually. "  Huh?  I asked if it was being denied because of the diagnosis codes.  "Juvenile Rheumatoid Arthritis is the primary diagnosis code, which is correct.  But this type of claim can't be processed automatically because of the type of treatment, and the type of claim."

So it was just automatically rejected?  Yup.  How come our appeal was rejected?  Because of the codes.  It was right.....but there was too much information.  And the computer....regardless of all of the documentation.....regardless of the doctor, taking his time and doing a peer to peer review.....the computer does what the computer does and through all of it....no one thought to check the claim to make sure the system was processing it correctly.

According to the Rapid Claims Resolution Center, everything will be paid and we will have updated documents in 10 business days.

But, "Aye, there's the rub...."  Baylee has her next treatment in 7 business days.  Do we risk it and risk another $7,000 (especially since it is also the day she has procedures on 4 joints to reduce the pressure from the inflammation)?  And because I won't know for 10 business, I still have to mount an appeal, fill out assistance paperwork (for assistance that isn't guaranteed)....and figure out how to pay the $14,000.....just in case.

So the stunning part....is that the doctors office has never heard, experienced or even knew that this kind of thing could happen.  It is unheard of to received an appeals rejection due to the computer system not being able to process a claim automatically.

A conundrum to be sure!

Lessons Learned
1.  I will fight for my children.  I'm not done fighting.....can you tell?
2.  I have sooooooooo many thoughts on insurance, government, regulation, greed, corporate corruption...blah, blah, blah....and this just riles me up.
3.  Is there a reason I can't process stuff like this unless I write it down?  Probably, but not going to figure it out right now.
4.  Ugh!  I hate having to fight for things!  I'm having such a Monkee's "Can't we all just get along?" moment!
5.  I suppose we would all do whatever is necessary to protect our children....and perhaps by one person standing up, someone else's children might get protected too.  Right now, I just want my daughter to receive the treatment that keeps her from going blind and becoming immobile....is that too much to ask?