Hello everyone, I've thought long and hard on whether or not to post this but when I hear so many being denied ketamine infusion treatment by their insurance, I cringe a little inside each time. I am going to share with you what I used to fight a denial by my insurance company; this may or may not help you, I sure hope it does and that is my only intention, to help. All this info was gathered off the web and put together for my insurance company, after which I was approved. I cannot guarantee this will work for you nor do I want to start a debate, this is only what has worked for me, and I hope it will help you to.


I would like to appeal a recent decision. My name is __________ and I have RSD/CRPS in ________________, which continues to worsen. I have had this for almost __ years now. My doctor and I requested that I be treated by __________________ using therapeutic intravenous ketamine infusion. With me having this condition for as long as I have, I have had many treatment therapies that have not helped. Ketamine infusion therapy has. Dr. ___________ cost for this treatment which includes the surgery center is _____________ for a 4 hour infusion.

The reason given for denial I was given was because Dr. _________ does not contract with your health plan and that I should find and seek a doctor that does. I have been to ________ doctors contracted in your plan, none are able to provide me with the treatment I need. I have called every pain specialist/anesthelogist that we could find in-network, and in the state of ___________, and can not find one that do these infusions.

Other treatment therapies used for RSD are:

SGB - $1400.00 per block
LGB- $5000.00 per block
Spinal cord stimulator- $57,000
Pain pump implant - $30,000 - $35,000 with refill running a monthly cost of anywhere from $200 - $300.

The first two are blocks and are usually given within the first 6 months of RSD and are only effective short term, and only a certain number of them can be given.

The spinal cord stimulator is used if you have a trial and it works or helps, then they proceed to implant it. I have had the trial by one of the top RSD doctors in ______________ and it did not work.

I had the pain pump implanted and after a year and a half, the doctor and I agreed it was time to remove it as it was not reaching/helping both upper and lower extremities. I suppose I could try the pain pump again but I would have to have two of them to reach all effected areas and then worry when I will need a liver transplant as the medicine will effect my liver.

I ask that you reconsider because after all the treatments mentioned above and all the medicines I have been on and tried, ketamine therapy has been the one that has helped. I do not wish to be on daily narcotics, again with concerns not only to my quality of life, but my liver. I first started infusions in ___________, going every 3 weeks for low dose infusion therapy. I then found Dr. ____________ who offered a higher dose which I did. I could not believe the difference it had made in my life, and in my pain.

Thank you for your time and consideration,

I also included the following documents with the above


Out-of-Network*Underpayment
On January 13, 2009, the New York State Attorney General Office published a 24- page* report concluding:
“The current industry model for reimbursing out-of-network care is fraudulent. The industry uses a conflict-laden database riddled with errors at the expense of the consumer.
The database is neither independent nor fair. This leads to chronically flawed decisions. Given the heavy burden of health care costs that working families must bear when insurers fail to pay what they owe, the out-of-network system must be fixed”.
Click here for the Attorney General's HEALTH CARE REPORT
On July 24, 2008,*Health Net Inc.*was ordered to pay $255 million to settle out-of-network underpayment allegations. Health Net insures 3.9 milliom members in New Jersey, New York, Connecticut, and on the West Coast, through several health insurance subsidiaries. The investigation found that some insurance companies "dramatically" under-reimbursed their members for out-of-network medical expenses. As a result, New York state Attorney General Andrew M. Cuomo issued 16 subpoenas to the largest insurers in the country, including Aetna, Cigna, and Empire BlueCross BlueShield.
On January 15, 2009, UnitedHealth, one of the largest health insurance companies in the United States, agreed to shell out $350 million to settle lawsuits that claimed the company shortchanged consumers and physicians when paying for medical services outside its preferred network.
The settlement would provide for payments to doctors who claimed they were underpaid and patients who said their plan didn’t cover enough of their out-of-network care. An independent third party will figure out who gets what.
*Aetna announced its own deal with the New York State Attorney General Office. The company will stop using a database developed by Ingenix Inc. (a company controlled by United health) to determine out-of-network pay and will kick in $20 million to help fund the independent third party.
*
WHAT TO DO IF YOUR INSURER PAYS LESS THAN YOU THINK IS FAIR
1. You have the right to appeal. Read your insurance materials and the notice from your insurer, called an explanation of benefits. It will explain how to appeal.
2. If you live or work in New York, the Attorney General’s Office may be able to assist you by advocating for you with your insurer.*Click here to file a complaint
3. If you do not live or work in New York, contact your local Attorney General’s Office for assistance.
Click here for the contact information for the State Attorney General for your state. You want to speak to a lawyer in the Consumer Fraud Division.






Here are some suggestions / talking points regarding reimbursement from insurance carriers for treatment with intravenous (IV) ketamine.
Treatment of breakthrough pain due to RSD / CRPS is an accepted treatment by all insurance companies.
For over 30 years, treatment of breakthrough pain with IV ketamine at doses up to and including those doses required for general anesthesia has been approved by the Food & Drug Administration (FDA).
Ketamine is approved as a “general anesthetic". Anesthesiologists, therefore, are most qualified to use the drug. For more than three decades, anesthesiologists have used ketamine to treat breakthrough pain in numerous clinical situations because of its unique properties.
For example:
¶ Breakthrough pain during dressing changes in burn victims (where intubation is not required because ketamine is a mild respiratory stimulant)
¶ Breakthrough pain during procedures in children (where no IV required because ketamine can be given IM)

¶ Breakthrough pain in asthmatics (where ketamine is a bronchodilator)
¶ Breakthrough pain in wounded soldiers (where ketamine supports blood pressure)
¶ Breakthrough pain in patients with RSD / CRPS (where ketamine uniquely inhibits the excitatory neuropeptide responsible neuropathic pain called glutamate and avoids the serious complications associated with the use of opioids - narcotics - to treat breakthrough pain).
**Two well-controlled studies demonstrate the long-tem benefits of outpatient ketamine infusions
Therefore, insurance companies are obligated to reimburse patients for customary and usual cost for the treatment of breakthrough pain with IV ketamine without further delay pursuant to PPO contracts.
Click here for supporting documentation by experts in the field stating that IV ketamine is the ideal medication for breakthrough pain in patients with RSD / CRPS
Ketamine is being used at the dose and route of administration as approved by the FDA to treat and control pain due to RSD / CRPS. Some insurance companies might try to argue that the FDA did NOT approve ketamine to treat RSD / CRPS. However, the FDA gave no specific medical condition / disease state as an indication for the drug. No medication has ever been approved by the FDA specifically to treat RSD / CRPS. Yet insurance companies routinely cover most medications to treat this neurological disorder.“Off-label” use of drugs is common in the USA and Canada.
In January 2009, the Canadian Government recognized escalating doses of IV ketamine on an outpatient basis as a treatment for RSD / CRPS.


KETAMINE INFUSIONS
Timothy Lubenow, MD
Rush University
Chicago, Illinois
Anthony Kirkpatrick, MD, PhD
University of South Florida
Tampa, Florida
Barry Friedberg, MD
University of Southern California
Los Angeles, California
*
*TREATMENT WITH KETAMINE:
Ketamine infusions have been reported to be safe and efficacious for the management of refractory complex regional pain syndromes (CRPS) in both the inpatient*[1]*and outpatient*[2]*settings. This therapeutic intervention can be especially helpful in the emergency room setting where large doses of narcotics (opioids) are often injected to control pain. The problem with narcotics is that huge doses are required because the neuropathic pain caused by CRPS is relatively resistant to the pain-relieving effects of narcotics. The use of narcotics often leads to hospitalization of the patient due to prolonged heavy sedation and respiratory depression. In addition, chronic use of narcotics leads to physical dependency, tolerance and constipation.
In contrast, ketamine has a very selective effect on relieving pain due to CRPS without causing prolonged sedation and respiratory depression. Therefore, ketamine is less likely to lead to lengthy and expensive hospitalizations. There is no problem with physical dependency, tolerance or constipation with ketamine.
In addition, ketamine "booster" infusions have proven effective in patients with severe, multiple extremity, intractable, CRPS. Most of these patients have failed all reasonable treatment options for CRPS. Ketamine booster infusions are likely to lead to fewer emergency room visits for these extremely difficult and serious cases of CRPS. The FDA-approved drug insert supports the safety ketamine:
"Ketamine has a wide margin of safety; several instances of unintentional administration of overdoses of ketamine (up to ten times that usually required) have been followed by prolonged but complete recovery.”**
*
The merits of using ketamine over narcotics to treat CRPS were presented at an international symposium held at the University of South Florida

The 2009 Coders' Desk Reference lists the following CPT codes for "Therapeutic Intravenous Infusions"
96365 - first hour
96366-*each additional hour.


1. USA DIAGNOSTIC CODES:
ICD-9 codes:
337.21 - Reflex sympathetic dystrophy of the upper limb
337.22 - Reflex sympathetic dystrophy of the lower limb
337.20 - Reflex sympathetic dystrophy NOS ( my doctor uses this for full body)
2. USA "PLACE OF SERVICE" CODE:
Surgery Facility: ___________________
___________________ ( address)
___________________ ( phone #)


3. Dr. _______________: ______________________ insert your doctor’s license number here.


Okay, that's what I used to fight my denial and I was then approved. I gathered all this information off the web, put it together with my appeal and sent it in. Maybe I was lucky but maybe just maybe they seen that this was the most cost effective treatment, I'm not sure, but it worked

Hope this helps someone,
Dee

Dee,
Thank you so very much for providing such a thorough template to submit the claims. I haven't yet tried submitting any of minebsince I know Aetna previously refused to pay for any of them but it's definitely worth trying now and your form would help so much!

I'm curious which insurance company you have? Also, I'm wondering if it's somehow a problem for the doctor if I submitbthe claims and do get reimbursed. My doctor has me sign something each time saying I'm aware there will not be insurance coverage for my treatment, etc. I guess I need to read it through more thoroughly but with all of the infusions I've had and will have, this could make make a huge difference for me financially.

Thank you so very much!

Dawn

Dee,

I am so glad you decided to post that. It was amazingly helpful! I always wondered how to approach these types of appeals. Now I have a template!

Thank you so much for putting this out there. Finding the time when I feel well enough to put something like this together is very difficult so this will make things go faster.

THANK YOU! THANK YOU! THANK YOU!

Totally agree! Thanks so much!

When I was denied by United Healthcare 2 years ago, I was advised by Dr. Getson's office to use the simple phrase "ketamine infusion therapy is an accepted protocol for the treatment of RSD/CRPS.".

I won my case with UHC upon appeal ( the 3rd or 4th time), with just those words. But UHC never remitted what they said they would in payment on my account. I am extremely fortunate that eventually I won my case in WC court in RI, and I don't have to fight with UHC for them to pay their fair share of the infusion expenses.

Good luck!

That's odd especially since UHC was paying Dr. Shwartzman. They were accepting BC/BS and UHC when I was there. Maybe it was a policy change that came after I started ketamine. I'm definitely planning to start sending some of the ketamine boosters going back to December in using Dee's form. It certainly can't hurt to try.

G'morning everyone,
I'm glad to see my post was taken in the way it was meant, to help. I have had many insurance companies and your almost always going to get that "denied" on the first try, that's when you appeal, and when I use the above mentioned info. I use the top part ( make shift template) then the bottom part:

Therapeutic Intravenous Infusions"
96365 - first hour
96366-*each additional hour.

1. USA DIAGNOSTIC CODES:
ICD-9 codes:
337.21 - Reflex sympathetic dystrophy of the upper limb
337.22 - Reflex sympathetic dystrophy of the lower limb
337.20 - Reflex sympathetic dystrophy NOS ( my doctor uses this for full body)
2. USA "PLACE OF SERVICE" CODE:
Surgery Facility: ___________________
___________________ ( address)
___________________ ( phone #)


3. Dr. _______________: ______________________ insert your doctor’s license number here.


Then I give the middle portion to them letting them ( insurance company) know I am serious and I will fight them all the way to a hearing if necessary, it has never gone that far, as I am usually approved.

I've had BCBS, Today's Option and Desert Canyon approve my infusions, those are the 3 off the top of my head. I really believe it's in the wording when you appeal ( just as Sandy has mentioned).

They are going to deny everyone the first time, that's just how insurance companies are but you appeal that decision, it will tell you on the denial letter how to take those steps. Insurance companies know that most won't appeal their decision or even bother to read the paperwork, this is where you get them. Once you appeal, someone other than the person with the big "denied" stamp in her hand who is stamp happy ( okay, maybe I exaggerated a little bit on the stamp lady ) but someone other than her will review your case, sometimes a group will look them over. Just don't give up, winning is possible.

One other thing, I would really read over that form that a doctor makes his patient sign about insurance and the infusion being paid, feel free to private message me if I can be of some help. I'm not sure why the doctor wouldn't help you get it covered, maybe I read it wrong, if not, please message me and I'll see if I can help, if you would like

We all stand together in this fight, every day more and more is being covered by insurance companies, because we are refusing to be denied treatments that work. I will help anyone who needs it, and then the next time you can help the next one who needs it, and so on.

My father is an Army man with quite the mouth, and my mother keeps telling me " you sure are your father's daughter" and I take that as the greatest compliment ever.

I'm here for you all as I know you all are here for me
Dee

BC/BS has paid for all of my dd's inpatient and outpatient procedures on the first submittal.

You are very fortunate. You are also very fortunate that your docs appear to accept as payment in full what your BC/BS is willing to pay - in RI, only WC victims are currently able to "afford" the one doc in the state that offers ketamine because the "co-pay" would approximate $1200-$1500 EACH infusion (only low dose outpatient infusions are available). We can "afford" it because its free, after lengthly and stressful WC court battles that result in limited treatment periods of 30, 60 or perhaps 90 days each.

My heart goes out to everyone who reads that simple sentence and feels the pain of knowing that their own health insurance company will likely never treat them the same way - I've been there...

Betsykk-i just want to clarify with you re: BC/BS paying inpatient and outpatient ketamine infusion. Did you have to obtain a preauthorization first or you just went ahead with the treatment and then bill the insurance. When they denied you, you appeal. Can you elaborate on this a bit more? I am seriously wanting to explore this option for myself because i have all 4 limbs involved.
I find this thread very helpful. I have yet to explore K infusion because i am afraid of the bills that i can not afford to pay.
Thanks.