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07-03-2014, 05:13 PM   #1
Cupkatemom
 
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Help with Insurance

So...after appeals from our doctor, Aetna is unwilling to cover several blood tests and fecal cal claims. What to do? My husband will be contacting his insurance person at work and will be filing an appeal with the State, but what else can we do. This could be $2k worth of bills every year. Anybody have any experience?
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Daughter dx Crohn's Dec. 2013
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07-03-2014, 05:42 PM   #2
my little penguin
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A lot of kids are covered under medical assistance due to crowns dx- it acts as a secondary insurance and is dx based not income based.
http://www.dshs.state.tx.us/CSHCN/

not sure if thats the right link
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07-03-2014, 07:33 PM   #3
my little penguin
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07-03-2014, 07:49 PM   #4
Cupkatemom
 
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Thanks MLP for your response and help. I should probably clarify my question -- I am not happy about the cost, but we can probably swing it. I am most unhappy with the response from the insurance company stating these tests are "experimental" when clearly they are a necessity to Crohn's patients. I think the insurance company should take some responsibility for these tests. Going without them could lead to greater problems and higher medical costs to the patient. I would think they could foresee that and thus be willing to cover these tests in the cost of their plans.

In the past few hours we've spoken to a health advocate at my husband's company who is going to investigate and help us...I was just hoping someone might have had some success fighting with the insurance company and point us in the right direction to get some assistance.
07-03-2014, 07:56 PM   #5
my little penguin
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Sorry no help there
Most insurance pick and chose what they cover
From a cost stand point .
Pill came are my favorite
If you don't have crohn's they are covered
But once you have crohn's they are considered experimental .
07-03-2014, 07:57 PM   #6
Farmwife
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Tagging in crohnsinct. She gets her big attitude from her vast knowledge of insurance companies. Perhaps she can help.

Other than that I'm not much help. I actually have the children's special health care through Michigan. It been such a big blessing to my family and I.
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I'm mom to............... Little Farm Girl 8 yr old
Ibd (microscopic)
(12/28/12),
dx Juvenile Arthritis
(12/13/13)
dx Erthema Nodosum
(8/13/14)
Bladder and Bowel Dysfunction
(10/14/13)
Ehlers-Danlos Syndrome dx (1/26/17)
Remicade started on (9/8/14)Every 4 wks
Azathroprine started on 10/9/15
EN/EEN- since (1/12/13)
Past Meds- LDN, Humira, Pred, MTX, Sulfasalazine
07-03-2014, 09:39 PM   #7
Clash
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Our fecal calprotectin stool tests aren't covered either. My son has them every three months. We have appealed but since they aren't considered standardized testing in CD then they are not covered. The ped GI feels this will change as their use becomes more common.
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Mom to
C age 19
dx March 2012 CD

CURRENT MEDS: MTX injections, Stelara


Dx May 2014: JSpA
8/2014 ileocecectomy
9/2017 G tube

PAST MEDS: remicade, oral mtx, humira
07-05-2014, 11:30 PM   #8
Brian'sMom
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Insurance can be a real pain!! Once our GI helped get something thru. But they helped us before we did the test..."Deemed it necessary for the health and well being of our son". So once you have already done it I'm not sure if the Doc's can help.
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Kathy, Mom of 14 yr old Brian
symptoms 2005, official dx 6/2010

Praying for Remission
Vedolizumab 8-8-14
Ileostomy 3/22/14
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Total EEN 12-10-13 to:TPN 1-29-14 - 4-2-14
Tried:Azathioprine,Pred,Pentasa,Cimzia Bi weekly & MTX 9/2013 to 8/2014, Humira 1/2011-9/2013, w/oral mtx 5 mos in 2013. Remicade: Had allergic reaction Jan 2011 Built up antibodies by 3rd infusion.
Has done round of Flagyl due to abcess 12/10 and 10-21-13 which helped both heal quickly.
07-06-2014, 04:21 AM   #9
lenny
Senior Member
We had to fight to get our insurance co. (United Healthcare) to pay for the Peptamen, but they've paid for the fecal calprotectin tests without any resistance.
07-06-2014, 08:31 AM   #10
momoftwinboys
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Join Date: Dec 2011
Sorry u r dealing with insurance issues. Frustrating.
We had trouble with Aetna paying for promethious spelling? test for aza levels.
I contacted the test company directly. They will send u the test kit for free. If u can get a lab to do a courtesy draw that they do not have a contract with and file as private the price was much better. Example gi clinic $982 with ins $568. Private $270 (pay within 30 days $170). I believe they will also try to help get insurance to cover. Aetna finally covered but it was good to know this was an option. My lesson learned sometimes if u work with company directly it is cheaper without insurance involved. Example of our messed up health insurance system.
Good luck with Aetna.
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Son (age 13) dx Crohn's October 2011 (age 10)
Azathioprine 10/2011-11/2012
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krill oil, multivitamin, liquid Vitamin D/Calcium/Magnesium, zinc, pro-thera complete probiotic.

"The decision to have a child is to accept that your heart will forever walk about outside of your body" Katherine Hadley
07-06-2014, 05:49 PM   #11
LJS
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When my son was doing EN, we could not get the insurance company to cover the formula. My doctor got involved, the entire department at childrens got involved, but we could not get them to budge. It was terrible..
07-06-2014, 08:57 PM   #12
Cupkatemom
 
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Thanks everyone for the responses. I've been thinking about this a lot...I think we need some sort of advocacy group to fight the insurance companies on behalf of Crohn's patients. I'm going to do some research in the next few months and see if I can come up with more information and ideas in how to go about this.

In the meantime, my husband tweeted Aetna and got some response from a worker who is now investigating. Gotta love social media!
07-06-2014, 09:38 PM   #13
AZMOM
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Our fecal cal's are covered. One insurance is covering the formula at a reduced rate but hubby's won't cover it unless you're a premature infant. Sigh.....

All these crazy exclusions depend on the plan.

Don't give up!

J.
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Mom to Claire - 11 going on 17

Dx JRA age 3, Crohn's age 6
Acute transverse myelitis at age 5

Started IVIG September 2016
Started Tacrolimus October 2016
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Folic Acid
Calcium/D supplement
Daily Vitamin
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No more Enbrel, Stelara, Methotrexate, Allopurinal or 6MP
07-08-2014, 09:34 AM   #14
lenny
Senior Member
When my son was doing EN, we could not get the insurance company to cover the formula. My doctor got involved, the entire department at childrens got involved, but we could not get them to budge. It was terrible..
We went back and forth with our insurance company for at least 6 months and they finally agreed to pay. And to our absolute shock, they paid 100% of the cost of the formula, well over $3000.

Now, I have extra formula that my son doesn't want, going to waste, as I erred on the side of caution, ordering more than we needed, as I didn't know if/when the insurance co. was going to change their stance, yet again...
07-08-2014, 11:05 AM   #15
my little penguin
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Oley foundation -takes donations and helps those who need formula /tube stuff
08-01-2014, 07:01 PM   #16
Cupkatemom
 
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Update - insurance has caved on all but the fecal cal (still pending) claims. Hooray. Not sure if twitter or the health advocate is to be praised, but I am super happy tonight. Keep fighting those insurance claims!!!
08-01-2014, 07:55 PM   #17
LJS
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You can let Oley Foundation know what you have, they will post on their site, adn then put you in touch with people who need it. They only pay for shipping..that is how I got some of the formula for my son.

Whatever I had left over I called up my home health care company, who provided the pump and bags, etc and donated over a dozen cases of formula. I only asked that they give it to a family who couldn't get their formula approved by insurance. I wanted it to go to families in need, as we were. They were so grateful!
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