Ridiculous request from my insurance company

[clifffaith]

Three weeks ago I was strapped into a spinal cord stimulator to see if it would work on me before being permanently implanted (supposed to scramble the pain signal to the brain). Test was supposed to last a week, but since I was getting no pain relief we recalibrated and I asked to go another few days. When the time was up, again still no relief, it was discovered that one of the leads had come loose so we got me reconnected, recalibrated again, and then went a few more days giving me a full two week trial. Bunch of snake oil as far as I'm concerned.

So Anthem has been sending me copies of the paperwork they are sending to my doctor, asking for more background on my situation, and basically dragging their feet on wanting to approve the surgery for the implant. Didn't work, so I don't care anymore, but today got notice that they were turning me down for the implant. "Your request tells us that you have had back pain for a long time. Pain can come from both the body and the mind. We need to know that you have seen a psychologist who has determined that your pain is not from your mind".

Where do I start. The physical therapy, xrays, two MRIs, 3.5 years with the Rheumatologist, 18 months of epidurals and various other spinal "tweaks" from the pain doctor, all of which have flowed through Anthem over the last five years, don't indicate to them that I have body pain and not "mind pain"?? And I guarantee I can make an appointment with just about any psychologist in the phone book, tell them what I've been doing to try to solve the pain issues, and they'll write a note that says "She really has body pain, and not mind pain". Anthem gives me pain in my mind as well as my behind!!

In any case, in spite of the "no surgery, no surgery, no surgery" mantra from the orthopedic pain doctor, it looks like it is time to go get a surgical opinion from someone "in network", followed by a second opinion from a doctor who is out of network who was referred to me by a friend. I don't want surgery, but my world has become very small when all I can do is putter around the house, do the grocery shopping (pushing a cart is fairly painless for me) or make a trip to CVS with my cane as long as it is fairly quick and the lines aren't too long because standing still is worse than walking after a few minutes. Can't do a museum, can't wander through cunning shops, can't walk two blocks from name-your-timeshare for dinner. Can't do it, and it is not in my mind!

 

[bogey21]

"Your request tells us that you have had back pain for a long time. Pain can come from both the body and the mind. We need to know that you have seen a psychologist who has determined that your pain is not from your mind".

The insurance company is the one that needs the psychologist!!

George

 

[VacationForever]

Sorry that Anthem is truly giving you pain. Since an implant isn't the answer as the test shows that it is snake oil material, has a spine doctor given you other options?

Reminds me that several years ago when I asked for sleep aid for my insomnia, my doctor said I had to see a psychiatrist first before they were allowed to make such a prescription. That did not go down well with me. Fortunately/unfortunately for me, I have another lifelong chronic problem that was never fixed by in the previous system (Kaiser) and my new Allergist here prescribed a wonder drug (a godsend!), which incidentally is used as a non-dependent sleep aid for other patients. One stone kills 2 birds.

 

[turkel]

Kaiser works really well for the healthy. Not so much for the sick or chronically ill. Generic drugs only unless you want to pay. As my brother says they treat Diabetes with 25 year old meds only regular insulin and NPH his A1C dropped 3 points once he left Kaiser and had access to newer medications. It costs him more but his health is priceless.

 

[turkel]

Anthem should have their head examined for this silly request!

 

[Talent312]

Are they paying for the psych-doc? If so, I'd humor them.
But I might also contact the dweeb who made that decision to laugh in their face.

 

[WinniWoman]

That is really crazy! I really hate insurance companies! I hope you can get this taken care of. So horrible to be in constant pain!

I was recently prescribed an eye drop prescription(Xiidra) for severe dry eye. Doc gave me a "discount" card that said first month free and $10 per month thereafter. Doc told me not to go through insurance. I get to the pharmacy and they say the card only works WITH insurance- read the fine print. Sure enough...

So- I get the first month free. Go back for the refill and they tell me $250 per month! Because the drops are $500 and the discount card only allows for $10 copay up to $250, and I have a high deductible plan, I have to pay $250! Well- NOT! And there is no Generic. And Restasis is also $500. Doc's office said no other alternatives.

So-ordered an over the counter drop- Retaine- on Amazon. Cancelled doctor follow up appt. The end. So glad I have insurance....

 

[rapmarks]

I am caught up in that expensive restasis business also.
My neighbor had polio in right leg and her leg isn't very stable. Her left knee is really bad, and she tried to get synvisc shots and insurance gave her a hard time. Now she is scheduled for knee replacement in July. Can't imagine how hard itbwill be with a weak right leg

 

[clifffaith]

Mom woke up the Friday before Memorial Day with her left eye streaming and in pain. Since then she has seen five different eye specialists, had an emergency cornea transplant, and two weeks ago had failed cataract surgery due to the amount of scar tissue left from the transplant (they'll go back in a few months and implant the lens in a different layer of the eye after she goes through another round of doctor's visits). The doctors prescribe what presumably are the latest and greatest medications, mostly drops but oral as well, and the insurance company will say "that drug isn't on our formulary". Mom whips out her checkbook, which at last I heard has $80K in it (BIG SIGH), and pays the $400-800 bill to get her Rx, and then gets on the phone when she's having a good day to do battle. She's done pretty well in getting the prices reduced so that her refills are considerably less.

And bless her heart, until it was evident that she was going to need a transplant, she pushed back big time when her insurance company wanted to send her to doctors way out of her large suburban Los Angeles city. She let them know in no uncertain terms she couldn't see to drive, her 85 year old husband couldn't drive that far and she wasn't going to inconvenience the rest of the family for multiple trips to multiple distant doctors every week. They backed down and let her see all local specialists until it became evident she was likely headed for a transplant. Since then my sister drives her 30 miles on city streets to the west Los Angeles office of the excellent cornea doctor who has an office full of caring staff. When the months away transplant became an acute emergency do it now situation that doctor was a godsend.

When it was clear that the neuro stimulator test was failing and I was scheduled to go back to see if they could adjust the programming, Mom sat me down and insisted she wanted to accompany to the appointment so she could understand what they were doing and why it wasn't working for me. I declined, but it is clear she'll do battle for me if need be!

 

[VacationForever]

Kaiser works really well for the healthy. Not so much for the sick or chronically ill. Generic drugs only unless you want to pay. As my brother says they treat Diabetes with 25 year old meds only regular insulin and NPH his A1C dropped 3 points once he left Kaiser and had access to newer medications. It costs him more but his health is priceless.

Agree. After we left the Kaiser system, which was the only system I had experience for more than a decade, we found much better doctors and medications here. It is really night and day. Every doctor we have now has a plan and follow-up. That is refreshing.

With one of my conditions, my new Allergist prescribed an effective medication known for treating my illness. I googled it and found that it had been prescribed for more than 20 years. I asked him why did the Kaiser doctors (dermatologist and allergist) not prescribe this medication but instead Kaiser had asked me to take 4 times the FDA recommended dosage of 4 different drugs all at the same time and they were still not working on me, so I was taking 16 times of the recommended dosage/treatment. He said "These doctors just don't know". Kaiser also subjected me to Ultra Violet therapy for about 3 months to scorch my skin twice a week, and nothing worked. I stopped the UV treatment because I was getting burnt and I was still not getting any relief.

My husband saw my doctor this year and the PCP looked at his drug list, which was prescribed since Kaiser days, said one of the diabetes drugs is really bad and it is prescribed because it is very cheap. He put a plan together for my husband to look at all his health conditions and ordered tests that Kaiser had never sought.

We are impressed of the medical care we get outside of the Kaiser system.