My insurance denied me getting my meds???

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Veteran Member

Date Joined May 2005
Total Posts : 511
   Posted 9/11/2009 4:40 PM (GMT -6)   
What right does Insurance companies have to denie someone getting the medication
they need??????????????????   I made some calls this morning to find out what the hold
up was on me starting on Cimzia.  I come to find out my insurance has denied me
getting it.  Has this ever happened to anyone else before??     I was busy at work and
didn't have a chance to call the doctors office but I will be calling first thing Monday
morning.  I guess doc has to appeal it, but what if they denie that?? devil
Living with Crohn's Disease since Jan./2000 but had a few years prior
I'm a true Crohnie with IBS and Arthrities too
Meds I have tried:  Too many to list- LOL
Meds currently on:  Tramadol for the pain
                               *Waiting to go on Cimzia                      
No Surgeries

Forum Moderator

Date Joined Nov 2003
Total Posts : 7116
   Posted 9/11/2009 4:49 PM (GMT -6)   
Often the insurance company needs more documentation than the doctor provided when the med was prescribed. Also, some insurnace companies require a patient to try one of the older biologics before starting a newer one. My insurance denied my Simponi initially until my rheumy provided information that I had failed Remicade and Humira.

I think my various insurance companies all denied my biologics at first. Then when the doctors appealed, I was approved. I hope your Cimzia issue is approved without much further delay.
Moderator Crohn's Disease  & Osteoarthritis Forums
CD, Ankylosing Spondylitis, lupus, small fiber peripheral neuropathy, avascular necrosis, peripheral artery disease, degenerative disc disease, asthma, severe allergy and a host of other medical problems.

Veteran Member

Date Joined Jan 2007
Total Posts : 656
   Posted 9/11/2009 5:28 PM (GMT -6)   
Don't panic! It is insurance company policy to flat-out deny many claims, in the hope that you'll give up and go away. I've been denied innumerable times. Each time, I've called my insurance company to find out the reason for the denial. I've called my doctor's office and told them what the insurance people are saying (which is usually something like "wrong code"), and asked them to resubmit. Sometimes it takes a round of two of this. But the insurance company has always caved--every single time.

Make sure to get all the documentation you can. If they tell you that the diagnosis code is wrong, make sure to get them to tell you exactly what code was submitted--and what code it should be. NEVER yell or get angry with the insurance rep--it's been proven that they respond better to a polite but firm customer. Keep asking them what you'd need to do to resubmit the claim. Sometimes they'll even tell you the exact wording that your doctor's office needs to submit. Stay cool, calm, and collected, and remember that they do this to everybody, as a matter of policy, to try to discourage you and your doctor. With luck, they'll give in. Go for it!

Veteran Member

Date Joined Apr 2008
Total Posts : 1753
   Posted 9/11/2009 5:33 PM (GMT -6)   
Mine wouldn't let me get my humira because I wasn't sick long enough. The thing is, nothing was helping, the bleeding wouldn't quit, and I literally would have wasted away. However, my doctor did appeal and basically fought with the insurance companies to get everything through. I did end up being able to get my medicine covered. Just keep trying...
20 years old, Diagnosed with moderate to severe Crohn's and Colitis in May of 2008.
Currently taking: Prednisone 5 mg, pentasa 2 pills 4x a day, omeprazole in the morning, and a women's multivitamin. I'm also trying a B vitamin complex, but it doesn't seem to be working so I'm considering the shots.
Diet almost completely without refined sugars, wheat, flour, gluten, high lactose dairy, and/or junk food in general.
Learning how to live again.
"He who has a why to live for can bear with almost any how."

Veteran Member

Date Joined Apr 2008
Total Posts : 1522
   Posted 9/11/2009 8:27 PM (GMT -6)   
They just hope your doc won't bother to refile the paperwork. Some docs can't be bothered and will just have you take something else.

I had one doc that claimed he didn't have time to fight the insurance companies every time they refused a medication and why couldn't I just pay out of pocket. The prescription would have been $65/month full price but only $10/month with insurance. It took him 3 weeks to finally file and I was approved. I fired him after that.

Regular Member

Date Joined Jun 2006
Total Posts : 321
   Posted 9/12/2009 5:12 AM (GMT -6)   
Cimzia is pretty expensive so I'm sure there are some serious guidelines for getting approval. I hope this doesn't shock you companies only care about money...they really don't care about you or me.

I worked for an insurance company for awhile so just be aware that they may not be able to tell you the diagnosis code that was submitted on your claim or other specific information. It sounds like naw has had some luck with one insurance company but we weren't allowed to give that information at the one I worked for. They looked at it like...its your doctors job to give you a diagnosis, not a customer service rep (you would be surprised by how many people have no idea what their diagnosis is) it prevents lawsuits (imagine they miscode it for cancer and I tell you have cancer...and you dont).

Anyway, what they WILL be able to tell you, no matter what, is what is wrong with the claim or why it was denied. You can then find out their appeals process and either appeal it yourself with information given to you by your doctor OR if you have a nice doc...they can appeal it for you. Most appeals get approved and even if it doesn't ...there is more than one level of appeals.

Hang in there!!
"Be ashamed to die until you have won some victory for humanity" ~ Horace Mann

Veteran Member

Date Joined May 2005
Total Posts : 511
   Posted 9/12/2009 10:50 AM (GMT -6)   
Thank you everyone!! I'm sure my doctor won't have a problem to appeal it. I just have to call Monday
and make sure he is. lol I didn't realize this was so normal so I feel better now. lol
Living with Crohn's Disease since Jan./2000 but had a few years prior
I'm a true Crohnie with IBS and Arthrities too
Meds I have tried:  Too many to list- LOL
Meds currently on:  Tramadol for the pain
                               *Waiting to go on Cimzia                      
No Surgeries

Veteran Member

Date Joined Apr 2006
Total Posts : 686
   Posted 9/12/2009 1:52 PM (GMT -6)   
Have your benefits administrator help also.

Remicade and 6MP

Veteran Member

Date Joined Dec 2006
Total Posts : 559
   Posted 9/14/2009 12:14 AM (GMT -6)   
LBJ said...
What right does Insurance companies have to denie someone getting the medication
they need??????????????????

The CEO of your insurance company needs a new LearJet. Somebody has got to pay for it, right?
Crohn's since 1988
3 resections

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