Mandatory dosing refusal raises serious problems

Some problems occur near the house. For me this was very close. On July 7, a six-page single-space letter issued by her daughter’s health insurance company denied the scope of her medication to prevent her daughter from blinding. She demanded a prompt response so as not to act unfavorably. The letter arrived about a week after the date stated and arrived by regular mail. If the message wasn’t clear, you’ll probably receive a second letter denying the press a few days later.

Despite their length, or perhaps because of it, the date and method of action required to prevent adverse effects was unknown. Remember, I’m speaking as a lawyer accustomed to reading this kind of thing, but for many of my clients, the claims are for nursing home medicaids or sometimes children with disabilities. The proper action to be taken after receiving these letters is virtually incomprehensible.

For example, notifications allow you to make either an internal appeal or an external review. You can make a standard pre-service internal appeal, a post-service internal appeal, or an emergency / quick internal appeal. For urgent / prompt internal appeals, you must “submit a prompt appeal within 5 business days of receiving this notification”. In this case, “1st level internal quick appeal will be completed within 72. Time for claim request …” Otherwise, by calling the plan within 4 months of receipt, “Standard External Review” You can do. Or, if you have a “quick external review” request, this will be reduced to “72 hours from receipt”. Of the decision to submit … “It continues. These weren’t the only issues with the letter, but you understand the point.

Fortunately, Dr. Jawaski, a Westchester rheumatologist at Alisa, and his staff, Lismorris, who are in charge of such issues, act very aggressively and swiftly, with very anxious days and communication. After filing, she was finally approved. Fortunately, my small family is near Paoli / Mainline, just a few blocks from the Chester County Hospital, which is part of Pennsylvania, as well as the Pennsylvania region, which is famous for its relative wealth. We also live in excellent health care providers and systems. health. I received such a notice in the American countryside and could only tremble in the situation facing someone trying to respond on my own. But here’s what was at stake.

For the past seven years, Alisa has been taking Humira, a biological “pen” type injection, for tubular interstitial nephritis with uveitis, an aggressive autoimmune disease that attacks the eye. rice field. Danger is not theoretical. We didn’t immediately forget her first race to the emergency room at EI DuPont Hospital a few years ago because she had lost her eyesight. Her ophthalmologist, Dr. Jin, and later her rheumatologist, Dr. Leffler, literally restored her eyesight. We saw it come back. Dr. Jin walked down the hospital corridor with us over the weekend as Alisa had been in the hospital for almost a week.

Over the years, Alisa has been taking a variety of medications, none of which worked consistently, with some side effects, including the final extreme side effects of Remicade Hospital infusions. When Humira was prescribed, it was consistently the only drug that worked as expected and without side effects. In rare cases, if not taken as planned, the inflammation recurred as expected and urgent steroid treatment was required. Therefore, the denial of coverage is serious, serious, and the results are predictable. At the same time I received the refusal, I received an invoice for four injectable Humira Pens per week. That was $ 16,024.58. The calculation is easy because you need 52 pens for a year’s supply.

The reasons for the refusal are stated as “experimental / exploratory” (although recognized biweekly) and either not approved by the Food and Drug Administration or “medical outline” (“recognized by medical care”. It is not supported by (described as a collection of medical references that have been made). “Expert”) or “Published Literature”. Another statement, “not prescribed or consulted with an ophthalmologist,” was not at all true. This statement regarding prescriptions by ophthalmologists was made by a doctor who is a doctor of emergency medicine in Utah, according to an internet search. The decisions on the remaining letters appear to have been provided by an Arkansas physician.

Lesson: It is very difficult for the average person to navigate the prescription drug system. We have to do better.

Janet Colliton, Esq. A certified elder lawyer. Her work, Colliton ElderLaw Associate, PC is limited to senior citizens law, retirement planning, life care, special needs, guardianship, and property planning and management, and her office is located at 790 East Market St., Ste. .. 250, West Chester, 610-436-6674, She is a member of the National Academy of Senior Citizens Lawyers and, along with Jeffrey Jones of CSA, co-founder of Life Transition Services LLC, a service for families in need of care.

Mandatory dosing refusal raises serious problems

Source link Mandatory dosing refusal raises serious problems

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