Aa
Aa
A
A
A
Close
Avatar universal

Assistance with insurance appeal

I have a 15+ year history of chronic migraine and pelvic pain. about 5 years ago I was put on a treatment regimen that literally gave me my life back. I was put on fentanyl patches round the clock and Actiq for breakthrough pain. At the time my insurance company covered it. Shortly before an unrelated insurance company change I received notification that the medication would not be covered anymore. We changed companies and the new company did not cover it either. I am in the appeal process at this time. I just received a denial for the first appeal. My appeal included my personal history, relevant medical charts, case-studies/articles supporting Actiq in non-cancer pain, in migraine specifically and opinion articles from Pain Management specialists who believe that it was silly to differentiate between cancer pain and non-cancer pain.
Essentially they are denying the coverage due to the fact that the FDA has approved the medication only for cancer treatment. I am hoping that identifying medications typically covered for off-label use might help. So I am looking for assistance with that...and just in general.
6 Responses
Sort by: Helpful Oldest Newest
136956 tn?1425606272
Do you have Endometriosis by chance? Migraines and pelvic pain could be a sign of it.
Helpful - 0
1326416 tn?1370927001
Please keep fighting this and appealing it until you prevail! In the event you lose your battle, there are some other drugs that will help you, although the one your on is probably the strongest one available at this time, unfortunately. This doesn't mean you will not have pain relief with some other medications, it means that you might have to be on higher than usual dosages in order to achieve the pain control that your used to. Since your current doctor is prescribing you fentanyl patches and lolipops, I don't think he/she will be "scared" to prescribe the higher dosages that will surely be necessary in your particular case. I think it's ridiculous, and totally unfair that an insurance company would even think of doing this to someone, especially if the patient has already been prescribed the medication BEFORE they took "took over" their insurance coverage. If you do lose your appeals, maybe there is some type of affordable supplementary insurance you can purchase. I know there are plans for prescription medications only. Maybe one of those can help you afford your current medication regimen. Maybe you can get the FDA to change their minds about the cancer only stipulation (good luck!). Unfortunately in the current medical environment, chronic pain sufferers are getting the short end of the stick. I'm very sorry that this is happening to you. Again, fight til the very end. you might win you know! Let us know how you make out, and GOOD LUCK,
                             shinty
Helpful - 0
1326416 tn?1370927001
P.S.---I'm sure you already know this but please be very careful where you leave your lolipops lying around (and the patches for that matter). I have heard of a child who accidentally sucked on a fentanyl lolipop and died from it. I'm wondering how it happened even though it was found, as I'm sure they are child proof to some extent. Where there's a will there's a way I guess. Take care,
          shinty
Helpful - 0
Avatar universal
Yes...I have endometriosis and intersticial cystitis
Helpful - 0
Avatar universal
Thanks for the support.I plan on fighting this as far as possible.My doctor has become more gun-shy than he used to be due to all the scrutiny over opiate prescribing.It makes me so mad that idiot doctors who don't monitor their patients closely and addicts doing dishonest things ruin it for the rest of us. It seems so unfair that I face having my life thrown into upheaval because an insurance company wants to save a few bucks!Anyhow, thanks for your support. Even though I don't have kids and rarely have kids visit me, I am very careful about storing my meds.
Helpful - 0
136956 tn?1425606272
When was the last time you had a lap or ultrasound?
Helpful - 0
Have an Answer?

You are reading content posted in the Pain Management Community

Top Pain Answerers
Avatar universal
st. louis, MO
317787 tn?1473358451
DC
Learn About Top Answerers
Didn't find the answer you were looking for?
Ask a question
Popular Resources
Find out how beta-blocker eye drops show promising results for acute migraine relief.
Could it be something you ate? Lack of sleep? Here are 11 migraine triggers to look out for.
Find out if PRP therapy right for you.
Tips for preventing one of the most common types of knee injury.
Here are 10 ways to stop headaches before they start.
Tips and moves to ease backaches