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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