United Healthcare coverage of ketamine infusions
 

I filed pre-determination papers with United Healthcare (I have a PPO Plan) for my upcoming 10 day outpatient ketamine infusions, with multiple day boosters afterwards (maybe 12 boosters just in the first couple of months).

United Healthcare sent me a denial letter, stating that "The Plan excludes coverage for therapies considered unproven, and the Ketamine is not covered." I immediately filed an appeal, stating that ketamine infusions are a recognized treatment for CRPS. I wanted to get the appeal on record as quickly as possible, so I faxed a quick letter the day after I spoke on the phone with one of their reps - before I even received a written documentation of the denial in the mail.

Based on discussions that I have seen here and elsewhere, it seems that there are many individuals that have managed to get United Healthcare to cover some of their outpatient ketamine infusions. How exactly did you go about it? Did it require enormous amounts of paperwork and long letters with lots of references to scientific literature? Or a phone call from your treating physician? How long did it take? Were you denied more than once?

Thanks for any advice and help you can provide. The cost for my treatments will approximate $30-$35K. My doctor requires cash, the only insurance he accepts is WC (which has also denied my treatments so far). So United Healthcare's funds would be a reimbursement to us for monies outlaid for my care (by my parents).

XOXOX Sandy

Sandy

I am sorry for your battle and disappointment with insurance...You know my story already about Drexel...I have MVP which I believe is carried by United Health Care..and I was denied with the reason of Ketamine infusions are considered experimental and not covered treatment..and somewhere in there it said in my denial letter that it was unnecessary. Oh shure thats not what my Dr. feels and why pushed to get me in there...Who are they????????? I ma so sorry..I too placed an appeal but funny I was allowed to give a dictated verbal appeal, possibly cux my appointment is in a week+ time..but have not heard back from the appeal. I won't be surprised should they deny me again..They are impossible and this is only for my first consult..I haven't even met Dr. Schwartzman yet let alone been given a treatment plan...

Don't cave to them..Stand up for yourself and try.. try.. try....

Hugz, Kathy

Thanks - you too....

I am 49 and this is the first time I have had to accept a "rescue" from my parents. I know they are happy to do it for me, even though they educated their kids with the hope (expectation?) that we would all be able to fend for ourselves...but this illness and the months out of work on a reduced income, etc., it's just been a lot for my husband and I to manage.

Right now I am trying so hard to ensure that they are rightfully reimbursed. Any advice or assistance that anyone has to offer would be gratefully appreciated.

Thanks, XOXOX Sandy

I had my appt. with Dr. Schwartzman yesterday and he recommended ketamine infusions. He wants me to do the 5 day but my insurance won't cover it. I have United Health care too. The women in the office who handles the insurance told me they won't cover it. She said the 5 day would be $18,000. The 10 day is $4,500 not including the dr's fees which my insurance will cover the dr's. Just wondering who gave you the price of $35,000? Did you see Dr. Schwartzman?
I was told that the price for the boosters is $200.00

Hi Sandy,
First, I am so sorry that you have to continue to battle for the treatment that you need and that could be a turning point for you.

I don't have any factual information to offer....only my hope that you continue to appeal, re-appeal, re-re-appeal, and try and find the fortitude to keep on it! Write letters, make phone calls, enlist your doctors to write letters of support.

I wrote letters, sent e-mails and my docs did the same for some authorizations that I had to fight for and were granted...albeit, it wasn't ketamine infusions (not yet...) but the persistance helped...

Has your attorney offered any advice or guidance on getting approval from United healthcare? Do you continue to pursue it with W.C. or is that a closed book re: the ketamine infusions?

I, too, would be curious to find out how others have received approval from United healthcare! Have you asked them about their clients who have received approval? i wonder how they would answer that question? (with honesty, I hope, as the phone calls are being recorded!!!!)

Sandy, don't give up...call up the newspaper, TV news station and let them know of your plight...some negative P.R.might push the insurance company over the edge in your favor!! I have seen that happen in the past..
As far as the loan/gift from your parents, if it were my daughter who was in the predicament we are in (RSD) I would do anything to help her!! I know you would do the same for your children, as children or adult children..
Your parents want to give their financial help along with their love...
Thinking of you,
Hope4thebest :hug:

Sandy -

If you're on a UnitedHealthcare PPO through work - your's or your husband's - it couldn't hurt to put in a call to the employer's Employee Benefits Dept., where they may have some leverage either through their broker or an in-house rep at UHC assigned to their account. They should at least be willing to take the time to read any studies or the like that you can fax into them.

Good luck!

Mike

Getson charges $1,250-$1,500 a day, depending on what's in your drip. His protocol is 10 day outpatient, followed by 2 days a week for a month, followed by 1 day a week for a month. I assumed a worse case scenario - $1,500 a day, for a total of 22-23 days, and rounded $33,000-$34,500 to $35,000. (The least amount that the bill would be is $1,250 times 22 days equals $27,500)

I don't know what portion of his bill is doctor's fee vs. meds.

My initial consultation fee was $400. I have already figured that I'll never see that again.

Sandy

Could you maybe email who said they got coverage? I had thought this too is not covered because it is experimental. I know if I do it in Tampa it is 7500 for the 3 days. The follow ups I did not look into as I am taking 1 step at a time I guess. I wonder why it is so expensive? Is it cause it is limited amounts available? Or cause it is new?

Sandy -

The argument with UHC is that if ketamine "cures" you, which might be read as a normal life with monthly boosters, $35,000 up front with maybe another $6,000/year for boosters is peanuts compared to the "present value" of another 16 years of healthcare spending (including Rx meds) at the rate you've probably been going over the last few years. This argument is particularly effective with the Employee Benefits Dept., if, as is not uncommon practice but unknown to the subscribers, the employer is actually self-insured and using the insurance company simply as its claims agent, such that each month/week the employer writes one check for what the carrier has paid out as a whole, along with an agreed management fee.

And I didn't pull 16 years out of the hat: at age 49, that's when your coverage probably switches over to Medicare. (Although who knows what year of age that might be extended to in the meantime, in what could amount to the ultimate budget balancing trick.)

And for those who want to know, "present value" is defined as the value on a given date of a future payment or series of future payments, discounted to reflect the time value of money and other factors such as investment risk. Check out the Wikipedia article for the formulas, if you want to see them. http://en.wikipedia.org/wiki/Present_value

And for a insurance companies, this stuff is second nature. The easiest example being so-called "structured settlements," where instead of a plaintiff collecting $X as a lump sum, and taking a huge tax hit to the extent that part of it is deemed by the IRS to have been paid for the present value (PV) of what would have been his or her's anticipated income stream to age 67+/-, the parties agree that the carrier will make a stream of annual payments, typically having a PV somewhat less than X (thereby saving the carrier money, assuming it has wisely predicted long-term interest rates) while the plaintiff, in turn, pays taxes at a lower marginal rate on the lost earnings component of the annual payment, such that the PV of the stream of the plaintiff's after tax NET payments is greater than what s/he would have received after taxes in a lump sum. (One of the issues for the plaintiff being in insuring continued payments even if the carrier goes belly up, sometimes done with a letter of credit issued by a "too big to fail" bank). But now I REALLY digress . . .

Mike

What is so pathetic about this whole thing is that Workman's Comp is actually the liable party. I am fighting with United Health because my WC case is still in the courts.

I put together a spreadsheet demonstrating how it was to WC benefit to pay the funds for the ketamine infusions and get me better and back to work, in lieu of my weekly disability and all the meds. At the end of 6-7 months it would save them about $30,000. I gave the computations to my attorney for him to show the adjuster.

I don't get it....we all know they don't have a heart or a soul. But it seems like they don't have any brains either...

Thanks Mike. I appreciate your input, very interesting. I have a call in to the benefits dept.

XOXOX Sandy

Dear SandyRI
Im so sorry to hear about your denial,,but not surprised,,health care and insurance reputations are nonexistant,,I payed for 2 years and fought tooth and nail for them to pay anything,,they keep kicking claims in hopes to beat you down to give up,,this whole world is corrupt,,this whole stinking world,,,the last year of my health insurance,as soon as I surpassed my pre-exsisting clause,put me on another network for which restarted my prexsisting for another year,,I called the commission office and everyone in the administration board,,theres nothing for me to do,,now everyone wont take me because they know of my RSD,,I dont have deep pockets either,,so,Im going to try to get into a health pool,,,Back to your story,,,,its a crying shame that the governorment doesnt step in to give people who despertaly need help,meds,treatments, to function,,I bet that ketamine bag doesnt cost them $2.50 a bag,,,,,,they just got to hype it up and add hidden fees to MILG {making it look good},,,,,,And to make it appear to be a reputable establishment to justify the cost,,,,,,,Yeah,Yeah,,Im not biteing on it,,,we all need treatment,,,I was told that the SCS was a astronominal price for me,,My I-pod {in reality ] is more sophistacated and cost more that a SCS,,,its all about the money,,someone needs to go to bat for us and get the treatment we need and to force the gov to do something,,,By the way,,I traveled to elpaso TX 2day and waited hrs to see a Drt about my condition,,jsut for him to look at me and ask what was RSD,,,this is the 4th Dr in the last year to ask me this,,,,,,,this grieves me,,,,,Good luck to you,,,I hope you get the ketamine,,,,but its track record isnt that good anyway,,,,Theres only 3 ways for me to be able to get proper treatment that will surffice me,,,{1} If I was a famous person {2} if I was a millionaire {3} from the hand of the Almighty,,,,,My money is rideing on the Lord,,Im sick of this place,,Thats why I'll be on my knee"s tonite, asking the one who can and WILL do something about this,,,,,,,,,,I bet if our president or anyone in congress got RSd,,there wouldnt be any problem for treatment,,,,Im too low on the food chain,,,,,,this world SUCKS

YIKES! Sorry you have to suffer this..

Bobber - and everyone else - thanks. I'm sorry for everyone else's struggles too. Life is not fair.

Bobber, my wife has had RSD since 2002 and fought the insurance racket for years and also doctors afraid of the DEA and fearing we were drug seekers. We no longer have insurance because of the system was able to rid my wife because of technicalities in the system. However, you can bet your bottom dollar all this will change in couple of months. The healthcare bill will pass. At the very least the pre-existing condition clause will be abolished and discriminatory practices in premium pricing eliminated. This will happen for sure, so hang in there! jim

Uhc
 

UHC covered my 5 day inpatient ketamine infusion. I think I paid about $2000.00 out of pocket,,,,

Debbie

Jim - Have you READ Obama's plan? There is a good reason so many want to start over....it truly sucks!! (Sorry to jump into politics here...)

I understand everyone's concern but, keep in mind Obama's plan is not UHC. In fact it compells for profit insurance to except pre-conditions. There is no "one payer" in the bill. In reality the bill restructers the US's insurance for profit system not healthcare but I do understand HMOs and how bad they are. I also remember our HMO controlling my wife's doctor so I certainly wouldn't want the government doing this also, but, push comes to shove you can lobby your government for change (hopefully), not so much so with UnitedHeathCare for profit insurance. By the way I'm a slightly right moderate who's withnessed alot these past few years changing my perspective a bit. If it were up to me I'd yank insurance company's Anti-Trust exemption, allow the fed to regulate the health insurance industry instead of each individual state. This, I believe, will compel the health insurance companies to really---really compete.

The only issue I have with tort reform is the monies saved is miniscule in relation to the big picture. One's premium may be reduced $30 over a year's span but will save insurance companies plenty and may not reduce doctor's malpractice insurance. In fact in some states where tort reform took place their rates increased instead.

The way the system is now, it keeps doctors and hospitals on their toes. It can keep the quacks to a minimum, and there are plenty of them out there and always have been for millinium. If reform is needed than it should be done to protect the patient not to boost profits for insurance companies.

HEY Jinks
I got an answer to my problem
I can pull a pull a bank job,,and make sure I botch the job cause I want to get caught ,,cause i dont want the money,its a federal crime so i'll pull it in a federal pen,, ,,so I will live in a nice facility,heated pool, chess games at noon,,movies evey evening,,,My own room free room and board 3 meals a day,coffee brought to me at 6 am,,they even will turn out the lights for me at 11pm,,,how nice is that!!! I get an x-box ,color tv in my own private room,,and free surgery and ketamine ,,,yippie,,,,,I can lay around watching soap opeas all day,,no more worrying about whether to use what money I have to either buy groceries with it or buying my meds..pill call 3 times a day,,,wow,,i wont need insurance,,,,they gotta takje care of me cause im federal property,,,,great,,,,,

Sorry but really, even here? People suffering from a dreadful medical condition, and the benighted, self-destructiveness emerges. Unbelievable.

People are dying, right now, because of the ineffable though certainly unacceptable situation we are currently mired.

C'mon. Pass this legislation. Then go back and push for more next year. And the year after that. Until the troglodytic forces on the right, who indeed do not care if you die as long as profit margins stay high and contributions stay just as high, are extinguished.

And this board can resume being a fountain source of knowledge and comfort.

-- dennis

Dennis,

Passing legislation that is bad in the first place just for the sake of "passing legislation" to make it "look good" doesn't make sense. The implementation date is not imminent. You are mistaken if you think that you are going to get health insurance in the next few months once the bill is passed. Why not fix it? Because they can, and then pass a decent version of the bill in time for the implementation date.

Did you REALLY READ it? Based on your comments, I don't think so. I want to be able to appeal decisions. And maintain access to my PM doc in Boston. And receive my lidocaine infusions when I want them. And get all my drugs (as WRITTEN) when I want them. And fight for my ketamine (with the chance of receiving it someday). Spend some time looking over the key points of the legislation and I think you will be really surprised at what you are really going to get.....

I am also deeply concerned about the state of the American economy. We cannot afford the deficit that this bill is going to generate as it is currently written.

I would expect that there are as many uninsured right wingers at the moment as there are left wingers. I think everyone wants health care reform - I don't know anyone who doesn't - do you? Its the right thing to do.

Enough politics....for me anyway.....

XOXOX Sandy

I have to intervene here and say I do hope this thread is not going to become derailed by political argument or members unable to disagree agreeably.

we try to interfere as little as possible in discussions, but when things become heated between members, we have no choice.

hopefully the topic can be resumed without becoming overly political (specifically partisan political) as well as with no more posts that are negatively directed against one another

thank you

Well Ive got the car gased up,,I could use a good wheelman,I'll swing by and pickup evryone on this board,,ive chartered a bus,,lots of food,tailgate party,,bankjob,,then off to the pen we go,,If we ask for a speedy trail,we could get a quick conviction,plead out,,and then move into out suites and get our free rsd medical treatment hopefully started by next week,,,,,,dress to impress,,,,,im on my way people to pick everyone up,,,bring your pets, i hear your allowed pets in a fed joint....

Giggle!!!!:d

Hey Bobber,
I love the idea of a road trip, though!! Let's go to Yosemite and Yellowstone, and soak in some medicinal natural hot springs! I had a visual of all of us RSD'ers being together on a bus, and understanding eachother's limitations and challenges as we cruise along the highway!! I love summer roadtrips!!! One of my favorites was driving up the coast to the San Juan Islands off Washington State and seeing the pods of orca whales in their beautiful natural habitat, swimming and living with graceful freedom....but I digress from the original topic..which indeed is of serious import....and on my mind constantly..
Hope4thebest :grouphug:
(just trying to lighten things up :grouphug: xoxoxoxoxox

My fmaily...

Swing by and pick me up!!!!:grouphug::grouphug::grouphug::grouphug::gro uphug:

Kathy

Can you pick up me and Lindsay on the way...there are a lot of hot springs here in Florida...I will take care of everyone! :)

:hug:Sandy

Hi Sandy, I am sorry to hear about your insurance dismissing the ketamine infusions. The lower dose infusions are now considered a treatment and is no longer experimental. I blue cross will pay for it, thats what I have as well as some of my friends and they pay every penny of it. I am not sure about other insurance companies whether they will pay for it or not, but I think they should as it is now approved by the FDA. I have been really lucky with my insurances both medicare and blue cross, without them we would be so broke by now. In all of just the past 2 years blue cross payed over 800,000 dollars in treatments, hospital stays, and air ambulances.

I hope by appealing it they will wake up and understand that this treatment could be the answer for a better life with less pain. What we told my insurance company was the ketamine infusions are cheap to getting SCS, and pump which costed me any where from 40,000 to 65,000 and it needs replacing like every five years. Then like me without the ketamine I am in hospitals sometimes lasting 3 weeks at a time which of course costs big time to, so giving me the ketamine keeps me from going in and out of hospitals and ER's. So in the long run it really is cheaper doing ketamine and helps so much better. I only wished I had done it sooner.

Do you have the dates yet for the infusions? I would love to meet you in person. I am having my surgery on the 29th and 30th of this month, but hopefully we will cross paths. I will be crossing my fingers that your insurance will take the appeal seriously and pay for the treatments.

Hugs!
Sam

Dear friend SandyRI
My apologies for the roadtrip detour. I am glad the last post from Sam was able to bring your thread back to its original, and intended topic...
Hope4thebest :hug: xoxox

Update??
 

My husband just landed a new job, and I will FINALLY have regular health ins again, praise God! This has been a long time coming. :) United Healthcare will be the ins co.

Ever since my CRPS went full body I have been wondering if Ketamine would help me. I don't know a lot about it but I am curious. I still have way more research to do on this. Looks like the last post on this thread was back in 2010. Does anyone know what UHC policy on this is now?? Any help would be greatly appreciated.

I hope this finds you all having a pain free, or at least a reduced pain level day!

I am going to be looking things up about insurance covering ketamine. I believe thats who the military tricare just went over to is United Health. I want to know what they will cover as far as my treatments. I don't want to have to fight this and insurance all at once. Its rotten that they don't want to cover a proven treatment. I wish you lots of luck in your fight with them. I am praying for all of us and so is my family. We understand what long term fights everyone with a chronic condition goes through. Keep smiling everyone and if yall do start a road trip to some hot springs stop in NM lol. I would love to go.:grouphug:

Yes, it is just asinine not to cover something that in the long run has the potential of saving everyone money. I mean never mind that some of us might get relief, because it's all about the money... right? I'm hoping that things have changed with UHC. I am also hoping that it's not a fight. We shall see. Thanks for the response hon!