Insurance says "no", now what?
 

I just got the letter today from my insurance company. They have decided that an SCS is not "medically necessary" and that I need psychological treatment. (Did I mention that they did NOT pay for the psych eval in the first place.) So now what? This is NOT in my head...this is real RSD that I've dealt with for 14 years. I started crying when I read that. I am so frustrated. I waited and waited for them to process my case and send it to insurance. Then I waited some more for them to respond...only to get this. :confused:

Appeal
 

That is awful!! There is a policy provision in most such policies to allow appeal of a negative adjuster opinion. Your doctor, if they are REALLY on board, might help in providing supplemental information to get a management review. I have been through this before, and the doc carried the ball. Game not over just yet!

Prayin,
Mark56:grouphug:

Thanks Mark56!

I wasn't sure if anyone else was having the same issue. I contacted the insurance company this morning and I CAN appeal, and I see the doctor again the 30th. But I DID find out that they are basing their decision on the physiologic report....it said that my pain was "psychologically based and I would benefit from psychological intervention." It also said the eval I had was "Not a clear evaluation of my current psychological state." I am so frustrated. Now I am just hoping I can get this appeal to go through.

Well insn't that interesting????
 

How in the WORLD could or would a physician who is involved in the implant process let you move forward to psych reveiw IF they were of a physiological opinion which contraindicated the implant in the first place?????? Boggles the mind?????


Mark56

Don't give up!
 

This is infuriating! Most of here have RSD and/or PN and we KNOW how real this is. Like Mark said, it will require a bit more paperwork Ooooo I SO want to slap your psychologist! :mad: and chances are that eval was based mostly on that stupid 20,000 question test, which is the most IMpersonal thing there is.
I never really understood the concept of these psych evals - of COURSE this affects us pychologically! Pain and depression pretty much go hand in hand and we are at our wits end...why ELSE would we be going this far to get pain relief! The other things they look for is if we have 'unrealistic ideas of what the SCS can do' or if there is a history of drug abuse perhaps, but I mean, YEAH, most of us would benefit from counseling because of what this pain does to our lifestyles. Stupid logic reasoning if you ask me.

Make your upcoming visit with your Dr count! Beg him with tears if you have to! If doctor's correspondence to your Ins includes mentioning that your quality of life is at stake, and that you can't hardly do basic day to day tasks, then this becomes a moral issue on top of a medical one. It wouldn't hurt to get a couple of letters, going back to your history and physical of the doctor who referred you, and maybe even a letter from your employer (if applicable)

I sure hope you at least get the chance at the trial implant. This will certainly say alot.

We're pullin for you!

:hug: Rae :hug:

Hi Puppyraiser8 :)
 

So upset to read that your insurance is being "ignorant" - to say the least. I agree with Mark, and call the insurance and set-up a grivance/appeal. Your doctor should go to bat for you and write a "ahem" letter to straighten them out.
It makes no sense that an insurance carrier would rather us be in pain, taking pain meds and having a non-existant life. Don't give up!! You will be in my prayers :grouphug:

Was the psychologist you saw through your doctor's office or separate? I really think you should get a second opinion from a psychologist- this one obviously is not good if the insurance even said it was "not a clear evaluation". A psychologist who deals with people with chronic pain is probably best, because they will have a better understanding of RSD and that it very real. Sorry you have to go through this, I can imagine how hard it must be to hear, but hang in there and don't give up- hopefully your doctor will fight for you! :hug:

Another argument to use to the insurance company (I used this one when calling to get approval) is that if successful, this will eliminate many medical costs in the future.

This is not right!!!
 

I just read your post and I'm so sorry :mad: that that are making you go through this. It isn't enough that you have pain and feel like crap and now get denied. Go and fight it!! Good luck :hug:

Appeal for sure!!
 

Hi puppyraiser8!

So sorry to hear you are having to deal with this on top of your pain! You certainly need to appeal and must have the doctor advocate for you. Make sure they file all the proper paperwork on your behalf with the insurance company.

In regards to the psychological evaluation, that is just a load of crap! Like Rae said, it was probably based on that test. When I had my eval, they told me I was depressed and needed further counseling before they would approve me...I was not happy. My dr told me to just go and talk to her, that she really didn't know me and it would be fine in a couple of visits and it was. After a couple of visits, she was comfortable with sending a new report to the dr since I told her that I could not get the SCS because of her report. Funny thing is, she told me not to let her hold the process up...did she not realize that everything was riding on her report??

Anyway, it all worked out in the end and I sure hope it does for you. BTW, I am a RSD sufferer too, have been for 19 yrs.

Wishing you all the best...Nanc
:hug:

How awful!
 

I am really sorry to hear that you are having these issues with your insurance company!......what more do you have to go through!?

Appeal their decision and make sure you make a song and dance about it and get this decision overturned. Its a disgrace!!!


I pray that you will have some good news in the New Year

Jackie :)