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Examples of Successful Patient Appeals and Pre-Determination Requests for Reimbursement

This  is a real story about two successful insurance appeals, provided to AAFA by an asthma patient who has given us permission to share it with others.  Although your health and insurance situation is unique, you may find this case study informative as you prepare your own appeal.

I am a 30 year old steroid dependent asthmatic who was diagnosed at age 23.  I have had 24 inpatient hospitalizations related to asthma and numerous emergency physician visits during the past eight years.  Because of the multiple hospitalizations and treatments, I have developed various comorbid conditions including osteoporosis, hypertension, hyperlipidemia, and most recently diabetes.

The first insurance challenge happened in late spring of 2009 when my doctor and I were seeking reimbursement for my treatment with Omalizumab (Xolair) for severe allergic asthma.  Coverage was first denied when we applied because my lung function test (FEV1) was better than what they classify as a ‘severe’ asthmatic. My doctor wrote a strongly worded letter that my life and health has been jeopardized by this poor decision and that I need this medication to have a healthy and productive life.  Eventually, the decision was overturned and I received this medication for the next eighteen months.  Unfortunately, I had an anaphylactic reaction to the medication and we had to discontinue this treatment.

My second insurance challenge happened more recently in September 2011.  My doctor proved I was clinically a “perfect” candidate with severe uncontrolled asthma for a procedure called bronchial thermoplasty.  My doctor sent lots of documentation, including his clinical opinion of my airways after he performed a diagnostic bronchoscopy, along with notations on my failure on all other medications known to alleviate and prevent asthma symptoms, plus my comorbid conditions caused by lack of adequate asthma treatment, etc.  However, the insurance reviewer denied the procedure because they felt there was not yet enough clinical evidence stating this procedure would make patients like me any better than I was at the current time.  My doctor replied to the insurer that based on pre-FDA approval clinical data that hospitalizations and ER visits were greatly reduced with patients receiving BT.  In addition, I pulled the explanation of benefits (EOB) from my insurer’s website and calculated the total amount of dollars they spent on my asthma-related care over the past year which amounted to over $150,000 (I was a very sick patient and frequently hospitalized).  I asked the insurer to take a calculated risk and cover my bronchial thermoplasty procedure as the costs of the procedure represented only a fraction of what they were already paying.. The insurance reviewer was finally in agreement. 

I have learned three key things about medical care and insurance companies.  First, as the patient you need to be insistent and not give up.  Second, the insurance company is always seeking to save itself money, so communicate the cost savings of the therapy you’re requesting, if there are savings to be seen.  Third, find a provider that wants only the best for you as a person, patient and paying customer – when all of these are considered you will have better chance of succeeding in your care and in your appeals for coverage of necessary services.



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