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Author Topic: Insurance Denial  (Read 19581 times)

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Offline RWEHEPC

  • Member
  • Posts: 34
  • Hep C Geno Type 3
Insurance Denial
« on: November 01, 2014, 07:51:01 pm »
Well our first attempt with CIGNA was denied.  The doctor is appealing but I have ever seen so many things that the insurance company wants. It is back an for forth between the doctor and the insurance company.

One thing I don't understand is if you have the insurance coverage why are you getting denied for the treatment.  It is all about that almighty dollar.  According to the nurse they last wanted my fibrosis count and how that was determined.  What does this have to do with it?  Make sure I"m on deaths door before they dish out the money and hopefully die before I start treatment.  :)  Geese  I'm over exaggerating here but that is sure what it seems lie.
« Last Edit: November 01, 2014, 07:54:04 pm by RWEHEPC »

Offline BattleTheBeast

  • Member
  • Posts: 817
  • Female, 57 - SVR12 as of 7/23/15!!
Re: Insurance Denial
« Reply #1 on: November 02, 2014, 10:14:52 am »
Hi RWEHEPC,

I am sorry you and a bunch of people are having a tough time with the insurance for the medication. I didn't notice what medications you were denied for. I think you may find some amazing resources and places to go where you get assistance and an advocate for the new medications. I think you go to www.mysupportpath.com for Harvoni or Sovaldi and it's http://www.olysio.com/hcp/patient-support for Olysio.

You can find the very easily via google by going to a search box and typing
"insert drug name" patient support. So for Harvoni you would type Harvoni Patient Support and the you need should be at the top of the list.

You can also search through the forums for excellent information from fellow members who have been there/done that. I went down to the search box on the bottom left of the forum screens and below the Stats you will see a search box. I went there and typed supportpath and got this link: http://forums.hepmag.com/index.php?topic=1313.msg3348#msg3348
It's a post from July and a member of the name "amocuatli"

Hope I helped a little and you can PM me if you need additional help and I will try.

~Mel~
~Mel~
Hep C, Type 1, 10/11  viral load 8,238,340, AST-60, ALT-57 Bili .6  Stage 4 cirrhosis,
Week 4 VL <15 AST 20 - ALT 27 Bili .9
Week 9 - switched to Harvoni VL UD!! AST 20 ALT 19

EOT date is 4/30/2015,
SVR 12 is 7/23/15 ACHIEVED!!! 
and SVR 24 ACHIEVED!!

Offline RWEHEPC

  • Member
  • Posts: 34
  • Hep C Geno Type 3
Re: Insurance Denial
« Reply #2 on: November 02, 2014, 11:29:41 am »
They denied me for Sovaldi and Ribavavrin for HEPC Geno 3.   Even though my doctor is going to appeal should I still go the Support path and fill it out and send it in?


Offline lporterrn

  • Member
  • Posts: 1,969
  • LucindaPorterRN
    • LucindaPorterRN
Re: Insurance Denial
« Reply #3 on: November 02, 2014, 01:23:17 pm »
You can call My Support Path and ask them - if you are denied twice and you make <$100,000, I believe they will supply the drug.
Lucinda Porter, RN
1988 Contracted HCV
1997 Interferon nonresponder
2003 PEG + ribavirin responder-relapser
2013 Cured (Harvoni + ribavirin clinical trial)
https://www.hepmag.com/blogger/lucindakporter

Offline BattleTheBeast

  • Member
  • Posts: 817
  • Female, 57 - SVR12 as of 7/23/15!!
Re: Insurance Denial
« Reply #4 on: November 02, 2014, 01:42:06 pm »
RWEHEPC, I signed up for mysupport because I wanted the availability of the 24/7 nurse support and also for the co-pay assistance program. Although I have insurance and was approved I am not opposed any help I can get, co-pay, a free nurse on call 24/7 sounds pretty good to me. Most of the form your doctor's office will need to fill in for you. I got the co-pay assistance by calling the 800 number. I didn't need the help fighting the insurance company so you can ask when you call if you have to fill out the paper.

I am no where near an expert person to give you advice so just sharing what I did and what worked for me, Good luck and I will be around if I can help in anyway,

~Mel~
~Mel~
Hep C, Type 1, 10/11  viral load 8,238,340, AST-60, ALT-57 Bili .6  Stage 4 cirrhosis,
Week 4 VL <15 AST 20 - ALT 27 Bili .9
Week 9 - switched to Harvoni VL UD!! AST 20 ALT 19

EOT date is 4/30/2015,
SVR 12 is 7/23/15 ACHIEVED!!! 
and SVR 24 ACHIEVED!!

Offline RWEHEPC

  • Member
  • Posts: 34
  • Hep C Geno Type 3
Re: Insurance Denial
« Reply #5 on: November 20, 2014, 01:25:33 pm »
I received my second denial for Sovaldi but got an approval for Copegus.  Lot of good that does.

I read in the denial letter that Based on the information provided, I am unable to approve coverage for this medication because: There is no indication of documentation of the degree of hepatic fibrosis (i.e., Metavir score or alternative) by liver biopsy or noninvasive testing.

In the previous requests from Cigna it was specifically asked for this information.  Since my Dr. did not have this available he states on the reply he has no knowledge of the score.  Wouldn't you think he would contact the patient and state in order for them to continue with the approval process we need to provide them with this information.  OK What do we need to do provide them with this information? 

My GOD!  I'm ready to through the towel in on this DR and start with someone else who actually is working for the patient.  I am so frustrated with doctors and insurance companies.

Offline RWEHEPC

  • Member
  • Posts: 34
  • Hep C Geno Type 3
Re: Insurance Denial
« Reply #6 on: November 20, 2014, 01:26:47 pm »
I might have to travel the Old Fashion way.

Offline Bucky

  • Member
  • Posts: 341
Re: Insurance Denial
« Reply #7 on: November 20, 2014, 02:57:36 pm »
I received my second denial for Sovaldi but got an approval for Copegus.  Lot of good that does.

I read in the denial letter that Based on the information provided, I am unable to approve coverage for this medication because: There is no indication of documentation of the degree of hepatic fibrosis (i.e., Metavir score or alternative) by liver biopsy or noninvasive testing.

In the previous requests from Cigna it was specifically asked for this information.  Since my Dr. did not have this available he states on the reply he has no knowledge of the score.  Wouldn't you think he would contact the patient and state in order for them to continue with the approval process we need to provide them with this information.  OK What do we need to do provide them with this information? 

My GOD!  I'm ready to through the towel in on this DR and start with someone else who actually is working for the patient.  I am so frustrated with doctors and insurance companies.

Hello RWEHEPC,
What did you insurance approve to take with the Ribavirin (Copegus)?
Bucky

I HAVE SLAYED THE DRAGON.....CURED SVR24!

Offline RWEHEPC

  • Member
  • Posts: 34
  • Hep C Geno Type 3
Re: Insurance Denial
« Reply #8 on: November 21, 2014, 01:12:21 pm »
I don't know why they approved the Riboflavin useless without the other.  My doctor called today and I need to go in for a specific type of blood test that will give him a liver fibrosis score. I have to fast for 8 hours so will be at the lab at 8:30 when they open the doors.

Offline rainbowray

  • Member
  • Posts: 263
  • Gen 1B
Re: Insurance Denial
« Reply #9 on: November 21, 2014, 05:58:42 pm »
RWEHEPC

Your Doctor should have had all those tests done before submitting. Are you sure you want him monitoring your treatment. There are better combos now than Sovaldi/Ribavirin.   If you can hold on and wait, I would get a better Doctor and bring all the current labs to him. Get a better combo prescribed. The ribavirin combo is not a fun treatment at all. I can testify to that.

Offline mike4777

  • Member
  • Posts: 5
Re: Insurance Denial
« Reply #10 on: November 23, 2014, 03:43:13 pm »
I was denied treatment because I am btw stage I and II.   I told by my doctor to appeal this and when the appeal is turned down I  will be able to call the support path number for Harvoni and appeal directly to them as I make less than 100K per year.  I hope it works, I was diagnosed with Hep C type 1B in 2008 and have been waiting for a better cure.  It's been 6 years, I feel worse and I may have to borrow the money, go to France and pay cash (51K) if the support path doesn't help. 

Does anyone know how I would purchase Harvoni in France? 

Do I have to engage a French doctor and do the treatment in France or could I bring the drugs back to the US?

Offline penny

  • Member
  • Posts: 52
Re: Insurance Denial
« Reply #11 on: November 23, 2014, 05:53:36 pm »
Hi mike
I think France has a nations health system which means it would be for their own citizens. But I don't know, if you pay 50,000 in cash they may take you, lol
Spain just approved harvoni but only for cirrhosis and transplant people. So no one can go there.
I think India will be the place to go since they will be getting it for like 2 grand per person. Heck, you can rent a house there for three months and still come out ahead.

Offline RWEHEPC

  • Member
  • Posts: 34
  • Hep C Geno Type 3
Re: Insurance Denial
« Reply #12 on: December 03, 2014, 06:27:54 pm »
Well I finally got the Liver Fibrosis score back.  Not sure what all this means, but I guess I am on the border of F1 and F2.  Below are my results:

TEST NAME RESULT FLAG UNITS INTERVAL
HCV FibroSURE
Fibrosis Score 0.32 High 0.00-0.21
Fibrosis Stage F1-F2
Necroinflammat Activity
Score 0.15 0.00-0.17
Necroinflammat Activity
Grade A0-No activity
Analysis:
Alpha 2-Macroglobulins, 209 mg/dL 110-276
Qn
Haptoglobin 140 mg/dL 34-200
Apoliporotein A-1 141 mg/dL 110-180
Bilirubin, Total 0.3 mg/dL 0.0-1.2
GGT 110 High IU/L 0-65
ALT (SGPT) P5P 30 IU/L 0-55

But I am sure that in the eyes of the Insurance company I'm not in level 3 or 4 so they will deny it.  Already planning on that decision.
« Last Edit: December 03, 2014, 06:29:32 pm by RWEHEPC »

Offline shEEEsh

  • Member
  • Posts: 10
    • OMiGosh : All Things Silver & Gold
Re: Insurance Denial
« Reply #13 on: December 06, 2014, 04:22:58 pm »
This was how the process went for me.

In September my doctor wrote me a prescription for Sovaldi and Ribovarin.

I took it to my insurance company pharmacy and they sent it to the insurance company referral department. 

Referral department denied it within 48 hours. 

At that time my doctors office filled out the insurance company's appeal form and in about two weeks my insurance denied the appeal.

I downloaded the Sovaldi application form from Sovaldi (about 7 pages) and had it filled out and signed by my doctor in October.

My doctor then faxed the denied appeal and the Sovaldi application to Sovaldi. 

Sovaldi reviewed the application and the following day they contacted my doctor and asked him fax their pharmacy my prescription.

The day after they received it my prescription and entered me in their computer my Sovaldi was shipped to my doctor.

Offline mike4777

  • Member
  • Posts: 5
Re: Insurance Denial
« Reply #14 on: December 06, 2014, 05:18:13 pm »
SHeeeSH,

Thanks for the info, I am going through that same process now, only with harvoni. I'm hoping that Gilead will do that same for me.  At the same time I am switching insurance companies from Health Republic to United Healthcare on Jan 1 in case Gilead does not assist after my appeal is turned down.

It's nice to hear that someone got some assistance from the drug companies!

Cheers,  Mike

Offline RWEHEPC

  • Member
  • Posts: 34
  • Hep C Geno Type 3
Re: Insurance Denial
« Reply #15 on: December 11, 2014, 02:57:28 pm »
I am just standing by now waiting for the results of the appeal to Cigna. 

Offline RWEHEPC

  • Member
  • Posts: 34
  • Hep C Geno Type 3
Re: Insurance Denial
« Reply #16 on: December 18, 2014, 04:16:16 pm »
I got a call from Cigna today and was SHOCKED that they approved me for Sovaldi and Ribavirin.  Will start when I get back from vacation in January.

Offline mike4777

  • Member
  • Posts: 5
Re: Insurance Denial
« Reply #17 on: December 18, 2014, 05:47:53 pm »
Congrats!  I'm glad you were approved, maybe they'll start approving others who need help. Cheers,  Mike

Offline BattleTheBeast

  • Member
  • Posts: 817
  • Female, 57 - SVR12 as of 7/23/15!!
Re: Insurance Denial
« Reply #18 on: December 19, 2014, 07:53:17 am »
I got a call from Cigna today and was SHOCKED that they approved me for Sovaldi and Ribavirin.  Will start when I get back from vacation in January.

RWE,

That's great news! Have a wonderful vacation and come back rested and ready to do battle with the beast!

Mel
~Mel~
Hep C, Type 1, 10/11  viral load 8,238,340, AST-60, ALT-57 Bili .6  Stage 4 cirrhosis,
Week 4 VL <15 AST 20 - ALT 27 Bili .9
Week 9 - switched to Harvoni VL UD!! AST 20 ALT 19

EOT date is 4/30/2015,
SVR 12 is 7/23/15 ACHIEVED!!! 
and SVR 24 ACHIEVED!!

Offline mike4777

  • Member
  • Posts: 5
Re: Insurance Denial
« Reply #19 on: March 09, 2015, 11:25:29 pm »
I have hep C type 1B and I finally received approval for Harvoni from my Insurance company, United Healthcare.  I am between stage 2 -3 with a viral load of 4.5 mil.  I have been taking Harvoni for a week and it's not bad so far. 

Thanks to all of the support on this web page, it kept my hopes alive.  Cheers

 


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