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