Insurance rejected request to cover enteral nutrition formula. Any ideas?

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Catasmom
Regular Member


Date Joined Sep 2009
Total Posts : 54
   Posted 1/15/2010 7:40 AM (GMT -7)   
Although defined as medical food, the insurance rejected our request for coverage. We even sent the labs to prove the stuff was working, along with the medical necessity letter from the GI.
Any great ideas out there? Experience?
I am sure I will encounter the same problem with the VSL#3 (although it is also defined as Medical Food!!!!)

I'm not giving up on this, so any idea, no matter how wild, is welcome!

Warm wishes from sunny Miami
Mom of a 12 year old girl diagnosed on Oct. 2007.
Prednisone (tapering off)/Asacol/6-mp/Vitamins (Centrum Kids)/Calcium (Oscal)/Probiotics: VSL#3/ Omega 3: Coromega/

did 6 weeks of Total enteral nutrition with Splash E028 and Vital Jr. (also tied Peptamen) (1900 cal. a day)

Put on 17 lbs in 11 weeks!!!!!!!
Eating normally for over 2 months... supplementing with 4 boxes of E028 Splash.
Symptom free!

Warm healing wishes from the Miami beaches....


flowery
Regular Member


Date Joined Jul 2008
Total Posts : 440
   Posted 1/15/2010 8:11 AM (GMT -7)   
If it were me...I'd make a stink..call your Local Represenatives. Let anybody and everybody you know what is going on. It is probably not covered because she is not a majority norm...but she's your child and she needs it.
Flowery
 "Get busy living or get busy dying"
Dx in 2005 with Crohns after a Hysterectomy. Re-section in 2006...came apart so got to do it again! Frequent Kidney stones and Shingles... a new present as of 08-09 Diabetes Type 2. Total of 12 surgerys.
Imran, Asacol, Colestid, Bentyl, Lamotil, Paxil, Nexium, Probiodicts, Vit D, Folic Acid, Lots of Potassium, Fish Oil, up to 6 Immodium a day. Oh, and one Giant Pill holder!
 
 
               
                        


HabsHockeyFan
Veteran Member


Date Joined Jan 2006
Total Posts : 3130
   Posted 1/15/2010 9:53 AM (GMT -7)   
I do not want to debate what insurance companies are for...I work for one. I do know that an initial rejection does not mean a final rejection. I had a vitamin rejected once as OTC and simply called to explain in further detail that I had the prescription level. No agruments and it was done.
Each person within a company has an authority limit. They will reject items that exceed their authority limit. I would recommend that you make a call and ask to speak to the case management team (or the supervising nurse case manager) to discuss the medical necessity of this. The case management team is usually staffed by medical personnel who have a greater knowledge of medical review.

Finally, I do know that most coverages do not include supplemental nutrition. So if the patient is able to maintain on regular food, this may be considered supplemental nutrition.

These are just thoughts I had for you
Dx'd '90 (emergency rupture), symptoms ignored long before that, '03 fistulas and bad flagyl reactions, B12 weekly, Pentasa [until I surrender to the bigger meds]
I'm riding on the escalator of life....


Illini
Regular Member


Date Joined Dec 2007
Total Posts : 298
   Posted 1/15/2010 12:29 PM (GMT -7)   
I second above suggestion. Contact the company again and speak to someone higher up. And keep trying.

I personally don't have any kind of coverage for prescriptions so I buy EN diets off E-bay (Peptamen, Nutren). Sometimes you can find things really cheap if the family no longer needs it for whatever reason.
July 2007 Drug-Induced Liver Injury
January 2008 Crohn's Ileitis
Currently trying... Enteral Nutrition, VSL#3, Primadophilus Reuteri, Folic Acid


Writer
Regular Member


Date Joined Aug 2006
Total Posts : 443
   Posted 1/15/2010 12:52 PM (GMT -7)   
I third the suggestion. If this is the first rejection, there should be an appeals process. I would keep it on a courteous basis for now (e.g., You understand this is a less-common treatment and realize they may need the opportunity to look over the data in more depth; you want to give them the opportunity to do so, etc.). If you did get to the point where you had exhausted all the appeals, then you could start looking beyond the company (e.g. state atty. general's office or insurance department or whoever regulates insurers in your state; your senator or representative, etc.). But I think you really do have a chance of prevailing if you just work through the standard appeals process within the company. If you need extra data, this recent review might be something useful to attach to the insurance submission:
 
http://www.ncbi.nlm.nih.gov/pubmed/19786755?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=4

On another note, she gained 17 pounds! Very impressive! I bet she's starting to look like a teenager, and is very happy about it.

Catasmom
Regular Member


Date Joined Sep 2009
Total Posts : 54
   Posted 1/16/2010 6:52 AM (GMT -7)   
It's always so good to be in this forum. You are all very knowledgeable. Thanks.
Mom of a 12 year old girl diagnosed on Oct. 2007.
Prednisone (tapering off)/Asacol/6-mp/Vitamins (Centrum Kids)/Calcium (Oscal)/Probiotics: VSL#3/ Omega 3: Coromega/

did 6 weeks of Total enteral nutrition with Splash E028 and Vital Jr. (also tied Peptamen) (1900 cal. a day)

Put on 17 lbs in 11 weeks!!!!!!!
Eating normally for over 2 months... supplementing with 4 boxes of E028 Splash.
Symptom free!

Warm healing wishes from the Miami beaches....

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