insurance refusal

[ez]

My 2 year old has been diagnosed with autism. He also was born with hypospadias which is a urological birth defect, and his growth has shut down, he has gone from the 75th to 25th to under the 2nd percentile. Because of this combination of issues, a geneticist at nemours has ordered 4 tests on him and also an mri, because a cousin has a brain malformation and we think he might be having seizures.
Anyway...my HMO FLORIDA HEALTH CARE has refused to authorize, saying they don't see how knowing if he has a genetic condition will affect his treatment. I can submit documentation and appeal if I like.
The geneticist had been confident these tests would be covered, so I admit I am very bummed. Has anyone been thru this appeal process. I am not a doctor, but it seems to me you dont have to be a rocket scientist to know why these tests are so important. Is it something that runs in families...are there other disorders assossiated that we havent seen in him yet...Kidney, heart...if he had a particular syndrome that has been identified, it would help us understand his prognosis, know what to expect...if its prader willi he might need growth hormones and have to watch his food consumption...if its SLOS he would need cholesterol supplementation. Thanks for letting me vent...like its not hard enough having my little bubbiwhup have all these issues...its like no one really gives a hoot. I can't help thinking whoever refused these tests would feel very different if it were there child or grandchild. If anyone has experience on what an effective course of action might be I am all ears. Thanks!

 

[NikiM20]

ez, i dont have anything to offer other than . I hope things look up for you soon

 

[tink1978]

I have not run into this particular problem before....but it might be good if you asked the geneticist for a letter to the insurance company explaining why the tests are needed and how they might improve treatment for your son. They will probably not listen to you, but they might the doctor. If they still say no, you may have to make do with the treatment that you can. Sorry to hear that this is going on with you.

 

[TurboKitty]

First of all, I want to give you this... Some of us do care.

I haven't been through anything like this, but I know the insurance company does not always serve your and your son's best interest. You are both only dollar signs to them.

Appeal, fight, advocate, do everything you need to for your son. Just be sure to keep records of everything; Who you speak to on the phone, copies of letters to and from the ins co, everything. (I learned this from fighting with the schools for my daughter, who also has autism.) Many times, the squeaky wheel does indeed get the grease.

I hope the tests are done soon and you find some answers.

 

[The Mystery Machine]

Anyway...my HMO FLORIDA HEALTH CARE has refused to authorize, saying they don't see how knowing if he has a genetic condition will affect his treatment.

First off {{HUGS}}....second, they are full of it.

When it comes to insurance you have to figure out how to force them to pay when it is necessary.
Generally the doctors you work with try and help you. However...these days it is tough.
You just have to push, push, push...You will get better working the system. Find loopholes, friendly doc's and organizations.

My dd is on growth hormone and was able to bypass some rules since she was "SGA" at birth, which was small for gestational age.

Since your son has fallen behind in growth you will need to track it. I went in every 3 months with dd and had her wt/ht checked and logged at her Peds.
After 1 yr. there was no denying she was not growing so off to the specialist.

Growth hormones are "new" so there is resistance from the medical community and people...
It is a daily shot, just so you know and there are risks as with anything.

 

[Teejay32]

Haven't had to do it for my own kids, but I've helped in the process a few times. Write a cover letter detailing what services you want covered, when and why - actually just take your OP, remove the references to the denial and polish it up a bit in letter form - then attach something from his primary care doctor (we got letters) and something from the geneticist (clinic notes have worked.) Find out who specifically you're going to mail it to, take care in addressing it so it gets there, etc. Appealing isn't always a futile effort.

Best of luck to you and your son.

 

[DisneyfeverTN]

I'm sorry you are going through this.

I agree with the other posters that your doctor needs to write a letter to the insurance company stating the tests are medically necessary. I work with insurance for our company and we have had employees do that and get something covered that would otherwise have been denied.

 

[Jpgirl]

Been there done that-my ds's genetic tests weren't covered either-I advocated, fought, appealed fought and appealed-never did get it covered. $400.00 for one test (fragile X). My ds wasn't covered for growth hormone either. He would've been if he had had insufficient growth hormone. He had plenty of hormone but none of it was being taken up by the receptor sites. He wasn't even on the charts. He was in a clinical for 4 years so we got it for free but he stopped growing as soon as it stopped. Thankfully he had a small spurt in puberty and he's5 foot today at 19.. Good luck I feel for ya