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Insurance denied treatment for HCV
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Insurance denied treatment for HCV

My insurance company (a Medicare HMO Advantage Plan) just denied me treatment for HCV saying it is not medically necessary.  What a bunch of crock, they have been denying everything lately.  I asked my doctor's office for a letter and they said they would send one but it hasn't arrived before the deadline coming up.  Help!
25 Comments Post a Comment
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Avatar_f_tn
In reading your other posts, I see you recently had a liver biopsy.  What were the results?
Advocate1955
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1280753_tn?1367761532
how can anyone here help you with the insurance co? HCV is a life threatening disease. i can't see how you would be denied if you have HCV. have you had a biopsy? have you had a blood test to determine your viral load?
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446474_tn?1404424777
What deadline??? To appeal the decision? You should have 60-90 says usually.

Call you doctor and tell them to fax the needed paper work to your Advantage Plan. Then have them call you after they fax it. Sometimes you have to bug people to make sure things get done. If the office misses the deadline, it will be many times harder to be covered for treatment later. You will have to appeal and explain why you appealed after the deadline. A real mess that you don't want to deal with.

Your doctor's office needs to meet the Advantage plan's criteria for approval. Make no mistake your doctor's office has dropped the ball, not the Medicare Advantage Plan.

Why does the Advantage plan say they denied you exactly?
Only "not medically necessary".
Your doctor's office as part of this HMO must know their criteria. Make sure they do their job.

Take action now or it will only get harder if the appeal deadline is missed.
I have been through this and it can be a bureaucratic nightmare. I have spent weeks on the phone trying to straighten  this stuff out. No fun.

Call your doctor's office tomorrow morning. Don't delay.

Good luck.
Hector
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4333925_tn?1359106042
Keep at them it took me 6 months w/ Atena and I got it approved. Talk to the one in charge and don't lose hope.  I know how it feels! There all a bunch of paper pushers that don't care but you will find someone that will help u.
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Avatar_m_tn
I see you say its a medicare advantage plan so I take it your going to keep this plan after the first of the year?

Being these plans are approved by medicare not sure how they can refuse treatment...... Good luck to you.
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Avatar_m_tn
Since you have until Dec 7th and have been having past problems with this plan it might be a good ideal to look into other plans in your area...
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1652596_tn?1342015226
you could always look into a clinical trial.  everything was free with no worries.    i did and my study nurse was fantastic.  i made it 48 weeks and last week she called me with the great news...SVR.  look into it.  btw...i also get paid in the end for being in the trial.  best wishes.  belle
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223152_tn?1346981971
Ow!   I certainly don't know much about Medicare yet, but I just applied for it this week in anticipation of my 65th birthday.  I wondered how hepatitis C would be treated under medicare so chose to treat before I turned 65 -- just in case -- while I still had great insurance.  Glad I did.

As I understand it, Medicare Advantage is like an HMO or PPO.  It is different from Medicare Part B and sometimes called Medicare Part C -- they are health plans approved by Medicare and offered by private insurance companies.  Medicare pays a fixed amount for care every month to the companies offering Medicare advantage plans and the companies must follow the rules set by Medicare.    MA plans had health and drug coverage.  This is not supplemental insurance.  Apparently they all work differently.

Joining switching or dropping a Medicare advantage plan:

-Before turning 65 (3 months before)
-If the Medicare is due to disability you can change  during the 3-months before the the 3 months after the 25th month of disability
-between 11/15 - 12/31 each year (and new coverage will begin 01/01 of the next year

Sounds like you may need to switch plans right now.

Kathy
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Avatar_f_tn
The same thing happened to me five years ago, my health plan told me I wasn't sick enough!  I've since switched jobs and have a new health insurance carrier that had no problem with treatment.  It's unbelievable that they could deny treatment.  Crazy.
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1654058_tn?1407162666
Keep at it. It seems like hard work with everything else you have to do just to get mentally and physically ready for tx. Grrrr. Don't give up. You have every right to treatment and any rescue meds if dr. orders it.
Karen :)
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Avatar_f_tn
Haven't gotten them yet.  Will get them after the deadline.
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Avatar_f_tn
My viral load count has been 2 million a couple of times now recently, its high.  I feel like crap, I have liver pain and burning and exhaustion.  They just want me to die rather than get treatment.
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Avatar_f_tn
I can never reach anyone at my doctor's office and left 4 messages asking for this letter the doctor said he would fax me and never did.  The ins. co. denied HCV tx based upon it not being medically necessary and the doctor wasn't in network.  The doctor IS in the network and is the ONLY dr. within the network who treats for HCV.
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Avatar_f_tn
Nope, I'm changing plans - just had surgery and need to find a new plan - any suggestions for a Medicare Advantage Plan with low co-pays?
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Avatar_m_tn
Your best bet would be to look in the back of your 2013 Medicare booklet, which should have plans that are in your area. They should have the basics like co-pays, cost, and if they include Medicare part D... Also their web-site is listed to give you more details and to see if your doctors are in the plan, you have until Dec.7th to make changes.

Sounds like a change in plans would be best.... Good luck to you.
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Avatar_f_tn
Thanks!
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1654058_tn?1407162666
No advice except to say hang in there. I changed ins 3x's since diagnosis. Just got a new medical bill yesterday. It creates a lot of stress trying to deal with all the paperwork. I'm not a health care insurance expert. Neither are you. I just wish SOMEBODY would do their job so that sick people would not have to try and figure it out.
Just my little spouting off self. I can't blame it on Riba rage anymore.
Keep pushing,
Karen :)
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Avatar_m_tn
As with ANY corporation, their job is to make as much money for the shareholders as possible. Their incorporation papers say nothing about suffering or helping people. What they say in the commercials is complete and total BS...Mark
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253566_tn?1219683299
Maybe talk with one of your local state reps. Ours is always having Medicare open house forums & maybe yours can help get things straightened out.

That is what local, state, federal government is suppose to be there for you.

Best of luck with it all.
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3722507_tn?1347972190
What is happening with your insurance company is terrible. As the patient advocate for Hepatitis Connect, I tend to recommend that our community members with similar problems investigate the clinical trials option. The best place to start is www.clinicaltrials.gov

By the way, I was cured of HCV in a clinical trial last year, and I have been clear for close to 12 months. The care was high and the results were positive. Right now, with several drug regimens without interferon and some without ribavirin, the side effects are lessened and the outcomes are better in the current trials. If you can, look for a late stage trial because it is always preferable. Stage 3 or Stage 4 are both excellent options. At Hepatitis Connect, Dr, Peter Ruana, one of our community advocates, is going to be posting an article about clinical trials by the end of the year where he discusses the positives and the challenges. Good luck, Susan, and all my best... John
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Avatar_f_tn
MY ADVANTAGE HMO HEALTH INSURANCE DENYED ME OF DME - CPAPA MACHINE AND MASK FOR NO REASON AT ALL BECAUSE I HAVE A SLEEP STUDY REPORT THAT SAYS I HAVE SLEEP APNEA   . IT MEANS  THE INSURANCE COMPANY  WANTS TO CANCEL THIER  INSURANCE POLICY WITH YOU AND YOU ARE BETTER OFF MOVING ON TO TO  BETTER HEALTHCARE INSURANCE
THAT IS WHAT I HAVE DONE!!!!!
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Avatar_f_tn
Good luck ever getting Medicare to do anything if you have any problem with your Medicare Advantage Plan - I filed 27 complaints and all Medicare does it lie = nothing.  My biopsy was not able to be read correctly as the surgeon took a slice instead of a core biopsy and screwed it all up - not to mention I've been having severe abdominal pain everywhere ever since the reflux surgery.  Medicare STILL does nothing.  I had to switch plans to another one next year just to hopefully get tx for this - meanwhile, 3/4th of my hair has fallen out now and I'm weak and in bed all day long most days.  Shame on the healthcare system if this is what you get after working all your life.  I had to file a "blanket Appeal" for all denials since my HMO refuses to mail me the denials and they did nothing about that.  I'm disgusted with the whole system.  Any attorneys out there?  I have a GREAT case, I permittedly recorded every single phone call and have both my HMO and Medicare agents lying on numerous calls.  Its a nightmare.
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Avatar_f_tn
I have filed complaints with both senators and my congressman and ALL have done absolutely nothing.  Beware, people, Medicare is a HUGE SCAM.
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Thanks so much!
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Avatar_f_tn
Thanks, but I can't negotiate the massive list of clinical trials by myself, I don't even know what the terms mean.  I couldn't find one where you don't have to have HIV also and I don't.
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