Insurance denies pegasys kit

[mgskye]

My insurance just denied covering the Pegasys kit - saying I do not have compensated liver disease.  I'm confused.  I was diagnosed with HepC  in 2006, I have been through all kinds of prequalification procedures to get ready for treatment, I've done everything they asked.  I had a viral load of 3 million when diagnosed, last viral count was 12 million.  I'm terrified of infecting my husband and step son.  Anyone have any idea how best to appeal an insurance denial of treatment?

[burned74]

I am a small business owner who buys insurance and deals with our insurance company on a regular basis.

I have not  seen a policy that gets so specific as far as what is covered and what is not. Is there anything in the policy itself that denies coverage as you have specified ? Your denial may well be based upon a mistake or misinterpretation of the policy by the insurance company employee.

I would send a letter with a cc to the state insurance commissioner (BTW a great move involving them already!!) to as many people at the insurance company as possible. You can get the names of the big wigs from the insurance company website.

Enclosing your doctors letter is a good idea. I have a feeling that you wont have to hire an attorney to get this resolved in your favor.

[mgskye]

I have also filed a complaint with the Texas Department of Insurance.  I'm not waiting for the second refusal, as a matter of fact, I'm hoping filing the complaint will alter their decision.  They told me it (my appeal) will go before some board at some unspecified time and then they'll notify me.  I hate the idea of having to resort to a lawyer but I'm pretty angry and willing to go that route too!  Good luck, Retired Dude, let me know how it goes!

[RetiredDude]

I am having same problem as you. We have appealed twice, insurance still refusing, gonna do one more appeal then lawyer up. Attorney will write them a letter stating why you need treatment, and your intentions to file suit for 200.00. Money well spent, just a shame a person has to go through this, isnt the hepatitis itself enough to deal with?

[IAmTheWalrus]

I like their "no sign of cirrhosis" comment. the objective, in my opinion, is to not wait until cirrhosis sets in because that can be too late.

In your case I think viral genotype would make a big difference. If you are 2 or 3, then the treatment is usually short with a likely positive outcome, and the risk of serious side effects much less. If you are geno 1, then you may want to wait (subject to previous caveat) for better treatments, since treatment for genotype 1 can be quite long with a less certain outcome. The risk of serious side effects seem to increase with the length of treatment.

Good luck in whatever course you take!

Brent

[mgskye]

I hope so, you're absolutely right about needing more information for peace of mind about treatment more than knowing how to appeal.  I'm pretty much asymptomatic except for an unusual amount of fatigue, I always keep a huge garden and canning/preserving was almost more than I could handle this year, which suprised me because it's one of my loves.  My viral load went from 3 million when I was diagnosed in 2006 to 12 million at last viral count in July.  I am a little frustrated now that both the GI surgeon who did the biopsy and my GI clinic practitioner kind of blew me off with "Your liver looks fine, no sign of cirrohsis" but I have to learn to ask better questions which I'm glad ya'll are helping me with.  I was concerned that with all  the warnings about side effects of the treatments, they said treatment can bring out problems that you didn't know you had before including permanent damage to kidneys, will bring out arthritis earlier, heart problems, vision problems, etc.  But are we EVER ready to handle more health problems?

[IAmTheWalrus]

I think your doctor will know how to appeal the denial. You do need to learn more about your situation in regard to viral load, viral genotype, HCV stage from biopsy and age; not just for the insurance company, but to help you in making and understanding the decision to treat or not. It kind of sounds like your doctor is on board with the idea of treatment now. Is this the case?

Anyway, best of luck!

Walrus