My insurance covers my Alere kit----- but I'm wondering if your doctor could write a letter of medical necessity to assist in getting yours paid for.

Doctors can do that for supplying brand name meds rather than generic---- mine does that all the time. But most insurance companies are really hard a**ed and yours might be.

Many have found that doing all the 'leg work' on the letter then presenting it to the doctor to have him add or delete what he thinks is necessary will speed the process up.
I know that my doctor has said that people who do home testing stay in range a lot better than others.

Here is an example of one kind of letter of medical necessity:


[Date]

[Contact] usually the medical director
[Title]
[Name of Health Insurance Company]
[Address]
[City, State, ZIP Code]

Insured: [Name]
Policy Number: [Number]
Group Number: [Number]

Dear [Name of Contact]:

I am writing on behalf of my patient, [name of patient], to request that [name of health insurance company] approve coverage for Kineret therapy for the treatment of rheumatoid arthritis. This letter documents the medical necessity for this therapy and provides information about the patients medical history and treatment, and a copy of the products labeling.

Patient History and Diagnosis
[Name of patient] is a [age] year old [male/female] with a diagnosis of [diagnosis] as of [date].

[Provide a brief discussion of patients symptoms and therapy to date.]

Treatment Information
Kineret (anakinra) is indicated for the reduction in signs and symptoms and slowing the progression of structural damage in moderately to severely active rheumatoid arthritis, in patients 18 years of age or older who have failed 1 or more disease-modifying antirheumatic drugs (DMARDs). Kineret can be used alone or in combination with DMARDs other than tumor necrosis factor (TNF) blocking agents.

There was a risk of serious infections (2% in Kineret patients vs 1% in placebo patients) in the clinical trials. Although Kineret should be discontinued if a patient develops an infection, most patients can continue taking Kineret after their infection resolves. Kineret should not be used with the TNF-blocking agents etanercept, adalimumab, and infliximab. A 7% rate of serious infections was observed in two studies with concurrent administration of Kineret and etanercept. The most common side effect was a reaction at the site of injection, usually mild, characterized by redness, swelling, and pain.

If you have any further questions, please feel free to call me at [physician telephone number, including area code] to discuss. Thank you in advance for your immediate attention to this request.

Sincerely,



[Physicians Name]
[Physicians Practice Name]

Attachments [original claim form, copy of denial or explanation of benefits, additional supporting documents]

[Date]

[Contact] usually the medical director
[Title]
[Name of Health Insurance Company]
[Address]
[City, State, ZIP Code]

Insured: [Name]
Policy Number: [Number]
Group Number: [Number]

Dear [Name of Contact]:

I am writing on behalf of my patient, [name of patient], to request that [name of health insurance company] approve coverage for Kineret therapy for the treatment of rheumatoid arthritis. This letter documents the medical necessity for this therapy and provides information about the patients medical history and treatment, and a copy of the products labeling.

Patient History and Diagnosis
[Name of patient] is a [age] year old [male/female] with a diagnosis of [diagnosis] as of [date].

[Provide a brief discussion of patients symptoms and therapy to date.]

Treatment Information
Kineret (anakinra) is indicated for the reduction in signs and symptoms and slowing the progression of structural damage in moderately to severely active rheumatoid arthritis, in patients 18 years of age or older who have failed 1 or more disease-modifying antirheumatic drugs (DMARDs). Kineret can be used alone or in combination with DMARDs other than tumor necrosis factor (TNF) blocking agents.

There was a risk of serious infections (2% in Kineret patients vs 1% in placebo patients) in the clinical trials. Although Kineret should be discontinued if a patient develops an infection, most patients can continue taking Kineret after their infection resolves. Kineret should not be used with the TNF-blocking agents etanercept, adalimumab, and infliximab. A 7% rate of serious infections was observed in two studies with concurrent administration of Kineret and etanercept. The most common side effect was a reaction at the site of injection, usually mild, characterized by redness, swelling, and pain.

If you have any further questions, please feel free to call me at [physician telephone number, including area code] to discuss. Thank you in advance for your immediate attention to this request.

Sincerely,



[Physicians Name]
[Physicians Practice Name]

Attachments [original claim form, copy of denial or explanation of benefits, additional supporting documents]

Once you have gotten the rant out of your system, calmly and carefully read your statement of benefits. You can get to it from your myUHC page as a PDF file. You do not have to bother your employer at all.

I too am covered by UHC. The statement of benefits describes consumables as not covered "unless necessary for the operation of said durable equipment", whereas the durable equipment IS covered. Your SOB may or may not be similar. Philips Remote Cardiac Services is in-network to UHC. When UHC turned down the submittal from Philips, I wrote a letter of appeal to UHC, specifically comparing the strips to diabetics' use of test strips, and specifying that the equipment cannot be used to obtain results unless the strips are used. I won the appeal and kept the appeal number on-hand for future orders with Philips.

Part of the problem is (or at least was) that the item was new enough that it had no coding of its own. Philips had ordered them as general supplies (A9999 I believe), so of course the claim was turned down. Besides, UHC has a claim denial rate of around 13%, making them one of the only insurers with a denial rate is even higher than that of government Medicare. Some people will not go through the trouble to write an appeal, do not educate themselves about the process, or may be too unpracticed or functionally illiterate to put a coherent letter together. It is all but a lost practice, and that much more so for the younger people. Regardless of reason, those who do not fight are the ones who end up paying. If you are within your rights then you can get past this, if only for the principle of the thing.

Still, I chose to augment supplies with some purchased off-the-shelf in order to facilitate frequent testing. The street price for test strips, such as those for Hemosense (Now Allere) and Roche, are considerably cheaper than retail. Just do a google search on "inratio 2 strips" or "coaguchek test strips" and you will find suppliers. $205 to $250 for a box of 48 is common. My last off-the-shelf purchase was from cliawaived.com. Sometimes Amazon has them as well. The expiration date was a full year into the future when they arrived. Results with those strips were essentially the same as those from Philips, so they were probably kept within specified conditions before they were shipped.

more2be----- that's very interesting news about cliawaived! I'd never heard of it before.

If I didn't have insurance that paid for absolutely everything, with no co-pay, I'd certainly look into that.

Chris, have you already submitted a claim for it and it was denied, or is this just based on your reading of the contract?

Contracts vary from carrier to carrier, and obviously what groups elect to provide their employees is likely based on controlling premium costs. Also, it's not unusual for this kind of thing to be excluded. Unless mandated by the state that governs the policy or certificate, I'm aware of contracts that cover insulin, for instance, but not the syringes, or will cover the glucose checker but not the test strips.

I'd argue that many insurance carriers will not consider test strips for a INR home machine as "medically necessary', since there are reasonable alternatives to testing an INR, ie, labs, doctor offices, etc. It's not like diabetes where home checking is paramount to controlling the diabetes. INR home testing is a convenience but not necessary to controlling your INR since there are alternatives for most people. I'm not saying that's right or wrong, just how it is sometimes. But it could be worth a try to take that route to see if your doc will authorize it as necessary .

Another option is always to appeal the decision, if a claim was denied, with the insurer, and then if not satisfied, submit an appeal to your state's department of insurance. May or may not help, but it's an option.

Another question for more2be------ if a person buys one of the cliawaived tests, is a doctor's rx needed? Or is a doctor's oversight needed ---like reading the test numbers, if they're not as easy to understand as the INR test results.

I've got United Healthcare too, but it must be a different coverage plan, since they cover everything (machine, strips, sharps) for me completely.

Of course, I've got CoaguChek and my doc submitted a prescription to the CoaguChek people who then worked with my insurance to get it all sorted out. Surprisingly easy, in my case, but I know it isn't always like that.

I'd definitely push back as well. Covering some strips every few months has got to be cheaper than ongoing lab tests. I would expect them to be on board with this sooner or later. But yeah, when I first called about coverage, they didn't seem to know what I was talking about. The machine was considered durable medical equipment, so that was easy enough to find the coverage for. But the strips and other supplies were a mystery. Pharmacy, maybe? They had no idea. Glad the CoaguChek folks figured it out for me.

Hope you get this sorted out.

The lab costs too depend on the insurance type. I go to an in-network lab. I think my INR lab work ends up costing me about $10 per INR test then, based on the network discount.

To answer Cave76's question, authorized suppliers of the meters, such as Philips, advise that those meters are suitable for those who have already had at least 3 months to become INR-stable under professional surveillance. By manufacturer's policy the meters, and I suppose the supplies, are supposed to be available by prescription only, but that does not mean that they do not turn up in other channels or that their market is not changing. Some suppliers will sell only to physicians, some will sell to anybody, and what comes through Ebay comes through Ebay if you absolutely have to go cheap and take your chances.

Traditional AC clinics are usually dead-set against changing to home testing. The actual reason is that they have been on a gravy train for 60 years, in which they have gouged from a captive population upwards of $140 per frequent visit just to run a test and say whether to go up or down half a pill. Their officially given reason is more paternalistic, that their patients are too doltish to figure out that a high INR means go down a bit and a low INR means go up a bit, or that they will misuse the knowledge of their own INR in some way. Similar things were said about diabetic self-testing when it was new back in the 70s and early 80s.

How far you can go off the leash varies from case to case. Some patients report their INRs to the remote service, which alerts the physician if it goes out of range. The service, such as Philips, may retain ownership of the equipment. In my own case I own the meter outright and I got it to where I can fax the INRs to the doctor, who authorizes dose adjustments. If testing on a weekend or holiday I have taken myself down half a pill for INR spikes. At least one hematologist, and one physician among my kin, are fine now with having their patients do their own half-pill adjustments for low or high INR.

Even without the greater degree of flexibility that some patients have, I still have brought the situation to where I am required to check in with a doctor only once a year, and that is about as good as it gets under the circumstances.

Thanks all for the IDs. Mine was medically prescribed by the doc. I own the machine. All I need is the test strips (also prescribed). Aetna would cover them automatically subject to deductible/copay. Normally, I call, Allere checks with the carrier for coverage benefits, then calls me back with totals.

UH's policy is a little confusing and perhaps contradictory. Aetna covered the machine (and I would argue it is) as durable medical equpment. UHC also covers "durable medical equipment." Supplies are covered to the extent they are required to make DME usable.

But in their exclusions, UH excludes under a section called "devices" "home anticoagulation equipment." But they don't define "equiment," and I've searched. Is a strip equipment? Supplies? Consumables? I don't need equipment, I need strips.

Still waiting to see if they will issue a rider on this.

Chris

It's usually considered a supply, if that helps.