Quote:
Originally Posted by Skooz
Kathy,
I am sorry, but sadly not surprised to hear of your troubles. I know that coverage for Ketamine infusions varies by insurer and by state. Coverage can also vary, for example, if your specific provider is in network or out-of-network. Even one part of the procedure (i.e. the physician's expense) can be in network and covered for a Ketamine infusion, but another part of the procedure (i.e. the surgery center expense) can be out-of-network and not covered, depending upon your specific doctor's contract.
I had a Ketamine infusion last year, so I became very familiar with the reimbursement specifics.
Question #1: Who is your insurer?
Question #2: Does your insurer cover Ketamine infusions in all or in part in any state? If the answer is "No", your chance on appeal is low because they will not want to set a precedent for the rest of us. The pre-surgery benefits coordinator in your physician's office can get the answer to this question for you.
Question #3: If your insurer covers Ketamine infusions in another state, is there anything in your plan to preclude you from going to another state where benefits are covered to seek treatment? If not - BINGO - go to that state and have a physician there do the infusion. I think from reading the RSD Association Newsletter that there was a discussion about states where certain insurers covered infusions. I know that if you posted your insurer on this site, there are others who have had infusions covered in all or in part in other states and could point you to physicians in those states.
Reimbursement for Ketamine infusions can be accomplished with creativity. My insurers did not reimburse any portion of mine, but I know that many of our peers have had theirs covered routinely.
Good luck to you, Kathy!
P.S. If you do find a physician with reimbursement, make sure that he is using the protocol per the most recent article published in the RSD Association Newsletter. It is considered the gold standard for infusions and not all physicians performing them are using it. Infusions are a high profit center for M.D.'s, so ask lots of questions and be informed.
|
Good morning skooz...
Very nice to get your note..my replies to your ins. quesions will probably not be as lengthy but I hope as informative..the name of my ins. company is MVP its thru my former employer.., I mentioned MVP in my post in the very beginning when describing the 5 committee member's responsiblities..the very first on being an MVP board of directors member.. To answer your question about coverage..the big stickler is my insurance considers Ketamnie to be completely experimental.. plain and simple..and yes, Dr. S is out of my network, that does not help, 2nd big stickler but the plain ole' word whether being said as "off the label usage" as Dr. S's office call it or as the ins. company see it ... it is being used as experimental...although it is being referred to as two different usages..Dr. S's office have said they have NEVER had a private ins. company approve this treatment.. but it is worth a shot..MVP will not approve it whether being in NY or Pa., not even portions of it.. Flat out forget it!! 5 day inpatient/10 day outpatient..Heck, they would not even approve my first visit there...consult, I paid for that out of pocket....
But as you can see I am not giving up...Someone has to be a first..and maybe you know but I am the type who puts her ducks in a row..and forces them to swim in a straight line! I also have NYS Ins. review group involved..but they are falling short seeing past the out of network part of it and are agreeing with MVP..as a denial..
I will keep appealing as this is my/our RSD lives I am fighting for.. not theres. Oh and I forgot to put this in my appeal verbage to you but..I also said something to the affect..if I was related to one of you, or you had a wife. husband, child or relative with this hurtful condition..there would be no choice in your mind what should be done for this person!
Hugz, Kathy
