Got to vent . . . Remicade denied

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Regular Member

Date Joined Apr 2009
Total Posts : 111
   Posted 3/2/2010 11:50 PM (GMT -6)   
I started Remicade in January due to daily vomiting (which they assumed was due to a flare, but it looks like it's probably gastroparesis). There were a lot of calls to the insurance company prior to this, but long and short of it, it was approved. First infusion was covered 80% by my insurance company.

Then my jerk of a GI decided that I must never have had Crohn's, since the scope was clean after I'd already started Remicade. He didn't even bother to look at the pill cam footage (it's been three weeks), stating that it's "probably normal" (which makes no sense, since I was diagnosed through a pill cam!). Despite him coming to the non-Crohn's conclusion, he told me to have the second infusion (which I did) and third infusion (next week). Doesn't make sense to me. I've got an awesome internist, though, and he's trying to sort through Dr. Evil's notes to figure out why I'm supposed to continue Remicade.

Very frustrating to have the diagnosis I got in 2008 -- which was confirmed by a second opinion -- replaced with IBS. Especially now that I've gotten the EOB for the second Remicade infusion:

*Remark Code O8: Based On The Information Provided, This Service Is Unproven For The Diagnosis Billed And Is Not Covered. No Benefits Are Payable For This Expense.

So basically, I'm on the hook for $5,374.15, none of which is eligible to be applied to my out-of-pocket yearly max, because the stupid GI changed the diagnosis from Crohn's to IBS for no reason.
Diagnosed with Crohn's in 2008 at the age of 22.
Currently on: Remicade, Imuran, Pentasa, Zofran, Tramadol, Welchol, Phenergan, Ambien, Metoclopramide, Omeprazole, Hyoscyamine

Veteran Member

Date Joined Sep 2006
Total Posts : 845
   Posted 3/3/2010 12:14 AM (GMT -6)   
have your hospital fight the insurance on the billing. Insurance companies are notorious for doing these kind of things and the hospitals will do everything they can to get them to pay when you tell then you can't afford it and they see that they covered the first bill. I once had an insurance company say they would not pay for a hospital stay that I was there for a bowel blockage. I was on the verge of being wheeled into the operating room but was finally able to clear it medicinally. The insurance company claimed that since no surgery was involved they would not pay for it. My hospital fought that since I was at risk for a perforated bowel I needed to be there. It took over a year but the insurance company did pay the whole bill despite the fact that I changed companies after this experience. The hospital was incredible in doing all the phonework and fighting and I never even had to talk to the insurance company. You just have to be the one to tell the hospital what is going on.

Regular Member

Date Joined Nov 2009
Total Posts : 380
   Posted 3/3/2010 8:15 AM (GMT -6)   
and, once you get that straight, get another GI.  there are really good ones out there.  Example,  mine called me saturday afternoon to check on me.  He knew my blood work has not been good and he wanted to see how i felt.  Saturday he called me after making rounds (he was the dr on call at the hospitals)  He also said he had another call into my internist to make sure the two of them were coordinated on my drugs and next steps.  btw his nurse always send me all my lab reports so i know what he knows. I di dask for this but he was happy to send them. 
This is what I call excellent service.  I hope you can find one that will gie you the same service.
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