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?

[Proactive]

Was cleaning bookmarks out of my puter,,you may already have this site, but Roche is doing a number of interesting trials with existing drugs...A good one for Canadians, 48 or 72 weeks of tx. Also an interesting one including predosing ribavirin..Maybe a trial is an option for some who have no insurance and can't get meds from the manufacturers or afford the bloodwork,docs etc.
http://roche-trials.com/patient/studies/cat10617.html

[kickboxingmom]

That is just Awesome.Good luck with your treating experience.I am happy to hear of your good news.Thank you for cheering ! I'll keep up with your story as you go along.As I am sure we won't be to far away from each other when we say,"SVR".Now go have a good weekend.


Have you heard about holding back one week on starting ? Just in case you would have a problem in future as being snowed in for an example.
Just a thought.It would give us a week to get problem resolved with less stress...Hope all your ducks are READY.Hehe
God Bless and Thank You,
Tammy

[mgskye]

We're at the same stage - Stage 1 Grade 0 Genotype 1a - Insurance REVERSED THEIR DENIAL!!!!!!!!!!!!!!!!!!!!!!!!!!  I did send a copy of the Complaint to the Texas Department of Insurance with my appeal, I don't know if that helped or not.  I just got the letter last night and I'm so relieved.  My doctor also sent copies of several studies with her appeal.  I did tell them that I was fully prepared to get a lawyer involved and held them responsible for my fiance or stepson being infected while treatment was being withheld.  Don't know if that helped or not.  Good luck kickboxingmom!  I'm cheering for you!!

[kickboxingmom]

Oops.Stage 1 Grade 0 Genotype 1a

[kickboxingmom]

Wow.I have been DENIED three times.
First DENIAL------- Dr. advocated for me.
Second DENIAL--------- Dr. did an appeal to appeal-In my Drs.conversation he even explained how Dr. Bacon said, the earlier you treat the better the outcome.
Third DENIAL-------------Sec.Treasurer of Union Hall advocated for me
Ins.said, I don't have enough damage at stage 1 Grade 1a.
Also I have it on paper that they'll pay 10k for a transplant and that's it.
I'm waiting now for one of the big kahunas to call from the ins. company
and I'll take it from there.
I'm researching now trying to find info on the earlier you treat the better.
My Dr. with my permission sent all my info to Dr.Bruce Bacon @ St. Louis U to see if I'm qualified to be in his REALIZE Trial. I'm thinking HARD !
Good Luck To All and God Bless With Conquering and Doing the BEST You Can To Knock'em Out and Win The Good Fight !
I Will Win ! It's In God's Box.......
Tammy

[RetiredDude]

Anyone ever see the movie John Q. Might have to do the same thing very soon. LOL        These hmos and group health insurance companies are a joke.

[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

[Isobella]

I'm in a drug trial as well.  It is a huge help financially to say the least!  

Lots of us are in the same boat as far as not sharing with friends.  Just one of the many ways this forum has been a live saver!!

Best of luck to you.  Please keep us posted on your progress.

Isobella

[mgskye]

Thank you everyone for the great information! Dr has filed an appeal, although they haven't responded to requests for copies of my labs and biopsy yet.  They did get me in a clinical trial that will cover my blood work during tx and up to 36 weeks after tx which was (or will be!) a big help.  And while my immediate family, closest friends and employer knows about it, it's not something I want to discuss with friends here so this forum is a blessing. I can't thank ya'll enough for your kindness in answering.

[Isobella]

You had posted that you wished to better understand the stages of liver disease.  I found this copy of an old post...I don't know who posted it originally, but it certainly helped me in the beginning.  

Definately take control of your care.  Get copies of all labs and reports to date.  Contact the assistance programs and keep learning....people here are glad to help.

Good luck to you!!




The Metavir scoring system for patients with hepatitis C when evaluating liver biopsies. The scoring uses both a grade and a stage system. The grade tells you about the activity
or amount of swelling and irritation (inflammation). The stage tells you the amount of fibrosis or scarring.
The grade is usually scored from “0-4.” An “0” is no activity, a “2” is moderate activity, and “3” or “4” are severe activity. The amount of inflammation is important because it may lead to eventual scarring or damage.
0 = no inflammation
1-4 = minimal inflammation
5-8 = mild inflammation
9-12 = moderate inflammation
13-18 = marked inflammation

The fibrosis score is also assigned a number from 0-4:
0 = no scarring
1 = minimal scarring
2 = scarring has occurred and is inside the areas of the liver including blood vessels
3 = bridging fibrosis (the fibrosis is spreading and connecting to other areas that contain fibrosis)   (Stage III)
4 = cirrhosis or advanced scarring of the liver

[kickboxingmom]

On the hepatitis c side I posted basically the same question about my second denial.I'll go bump it to the top on the other side.I think you'll also find it helpful

.Thanks to everyone for ALL the Helpful Info.Again, you guys are so whats the word ?Hmmm Take charge kind of people ?
Leaders in this fight against HCV !
Tammy

[Proactive]

Pegassist (Roche Pegasys system): 1-877-734-2797

Commitment to Care (Schering- Plough PEG-Intron system): 1-800-521-7157

here is scherings care site
http://www.schering-plough.com/schering_plough/pc/commitment_care.jsp

application from to get things started...but as I say, you have to go through the hoops first
http://www.schering-plough.com/pdf/commitapp.pdf

[Proactive]

You are going to have to take control of the situation. Request a copy of your biopsy report, get copies of all blood tests. get (keep a copy of the insurance denial letter (you have to be denied twice in order for some of the drug companies to kick in drugs and they will rewuire denial copies). Your doctor is the one who needs to be involved in the appeal and send an appeal letter to your insurance company.
Research your policy, you may find hep c reference...typically you need prior approval to get these drugs..
best of luck, pro
(I'm sure someone, Bill? will post the drug co assitance #'s)

[nygirl7]

I had insurance that paid for a full year but wouldn't cover my extension to 72 weeks.  Comittment to Care (for PegIntron) paid for the pills and the shots for the next six months. I called them and they couldn't have possibly made it easier if they tried. I mean not only were they nice and helpful but they actually wanted to do everything they could. they have real professionals there who will help you every step of the way.

And please contact your doctor and have HIS office contact your insurance.  If a doctor feels you need and deserve treatment it should be so.  Knowing your grade and stage he should have his medical billing pro's get involved to get this done. People who are stage 1 are allowed to treat!

[moahunter]

Pegasys assisted me, before my insurance kicked in (I had a 6 month standby time, but needed urgent treatment as acute). They are very reasonable - essentially you send a breakdown of your monthly income / outlays, and if insufficient spare to cover, they may assist. Perhaps pegasys would also apply pressure to the insurance company?

[fretboard]

I just realized that the information that cottoncandy gave you is correct as I vaguely remember that someone was in the same position as you're in and they contacted Pegasys.  Contact Pegassist or Roche, just google it and look around.  later

[Liz50]

I ceratinly understand frustration with the ins. co...and do fight them on this..get more info from your doc & get him/her on board. Ins cos make decisions based on numbers and facts and criteria, not on people and needs. If your doc feels you need to do TX then that should be all you need. But you may have to provide more info.
As for infecting your husband and stepson...so highly unlikely. My hubby had HCV for 25 years, we had 5 kids befpore he even knew he had the disease and NONE of us have it. It is very, very hard to pass long. Just keep the razors and toothbrushes separate. That's all our docs warned us about. That concern should not even cross your mind.
Best of luck with the ins co!
Liz

[mgskye]

Wish I did have more information.  I had a liver biopsy in September when they removed my gallbladder and both the surgeon and my GI doctor just told me my liver "looked good, no cirrohsis".  I am frustrated that I'm not better informed - I didn't understand about the stages the liver goes through before failure and I just wrote my doctor and asked for a better explanation.  The insurance denial said there was no sign of compensated liver disease - does this mean I don't need treatment??

[fretboard]

Sorry to hear that you have to deal with a knucklehead of an insurance company.  lol  Maybe you can give more information of what your biopsy showed.  You really have to make certain that you have all your ducks in a row when you're dealing with any bureaucratic entity.  Sure your viral load is high, but that could easily be attributed to something else and doesn't speak that much about your HepC at all.  I have not had to fight an appeal, so I won't be able to help you in that area, but along with the question you are asking, maybe you should supply more information.  God Bless