second-level appeal letter

[ammmum]

What is the name of your state? New York

I'm about to file a second-level appeal and I just want to make sure that the following letter made sense.

Dear Board Members:

This appeal qualifies for an expedited appeal. Delay in [HMO] benefit determination, subject to the standard appeal time frames, could jeopardize my ability to regain maximum function of my sinuses. Additionally, I have attached my physician’s letter stating that the standard appeal time will subject me to severe pain that cannot be adequately managed without the treatment that is the subject of this appeal.

In a letter dated 10.29.2006, [HMO] Senior Coordinator, [YYY] wrote that the [HMO] Medical Director “...determined that the requested procedure will not be covered for the following reason(s): “frontal and maxillary sinuses are clear during symptomatic period and limited ethmoidectomy is covered under CPT code 31254.....” After a first-level appeal was filed on 09.29.06, in a letter dated 10.06.06, [HMO] Senior Coordinator, [ZZZ] wrote that the [HMO] Medical Director “....Based upon the review of all available information and the terms of your plan, our medical director has decided to uphold the initial adverse determination because the frontal and maxillary sinuses are clear during symptomatic period and limited ethmoidectomy is covered under CPT code 31254. Therefore, medical necessity has not been demonstrated and services are not certified.....” The [HMO] Medical Directors’ determinations are not valid. “A diagnosis of sinusitis,” which has been clinically determined by my doctors, is required. Both [HMO] Medical Directors agreed that I have sinusitis, demonstrated by their approval of CPT code 31254 “Nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior).” A diagnosis of sinusitis specific to all individual sinuses, as both the [HMO] Medical Directors’ site, is NOT part of [HMO] guidelines.

The [HMO] guidelines, that are attached, state that endoscopic nasal surgery will be covered if the following clinical guidelines are matched.

• 3 or more office visits with the diagnosis of sinusitis AND
• 6 weeks of antibiotic therapy consisting of 2 different antibiotics with a trial of Cortisone spray and /or decongestant AND
• Persistent upper respiratory symptoms and/or treatment for an on going sinusitis greater than 3 months OR
• A complication of sinusitis (e.g. cellulitis and/or abscess of the orbits, septum or eyelids) osteomyelitis or meningitis OR
• CT scan with the findings of severe nasal polyposis

I have met all three required guidelines, for nasal endoscopic surgery. On five office visits, I have been diagnosed with sinusitis (05.11.06, 08.28.06, 09.18.06, 09.25.06 and 10.04.06), by [HMO] participating providers [XXX], MD and [WWW], MD. I have attached the notes of Drs. [XXX] and [WWW]. I have completed six-weeks of antibiotic therapy consisting of three different antibiotics (Amoxicillin, Cefuroxime, and Ketek) with a trial of cortisone spray (Nasonex). I have attached my pharmacy receipts from 05.11.06, 08.28.06, 09.18.06, 09.25.06 and 10.04.06. I have had documented, persistent upper respiratory symptoms for ongoing sinusitis, for more than 3 months. In addition to my doctors notes, I have attached my MRI films, MRI reports and a CT scan report from 04.06.06, 05.08.06, 08.14.06 and 09.15.06.

The [HMO] surgical guidelines state that ethmoidectomy, maxillary entrostomy, frontalsinusotomy and sphenoid sinusotomy will be covered if the following clinical guidelines are met:

• Treatment for sinusitis and/or respiratory symptoms should have been rendered within the past year AND
• 3 or more office visits with the diagnosis of sinusitis AND
• 6 weeks of antibiotic therapy consisting of 2 different antibiotics with a trial of Cortisone spray and /or decongestant AND
• Persistent upper respiratory symptoms and/or treatment for an on going sinusitis greater than 3 months OR
• An acute respiratory infection unresponsive to initial antibiotic therapy of 24-48 hours OR
• A complication of sinusitis (e.g. cellulitis and/or abscess of the orbits, septum or eyelids) osteomyelitis or meningitis

I have met all four required guidelines, for ethmoidectomy, maxillary entrostomy, frontal sinusotomy and sphenoid sinusotomy . On five office visits, I have been diagnosed with sinusitis (05.11.06, 08.28.06, 09.18.06, 09.25.06 and 10.04.06), by [HMO] participating providers [XXX], MD and [WWW], MD. I have attached the notes of Drs. [XXX] and [WWW]. I have completed six-weeks of antibiotic therapy consisting of three different antibiotics (Amoxicillin, Cefuroxime, and Ketek) with a trial of cortisone spray (Nasonex). I have attached my pharmacy receipts from 05.11.06, 08.28.06, 09.18.06, 09.25.06 and 10.04.06. I have had documented, persistent upper respiratory symptoms for ongoing sinusitis greater than 3 months. In addition to my doctors notes, I have attached MRI films, MRI reports and a CT scan report from 04.06.06, 05.08.06, 08.14.06 and 09.15.06. Furthermore, a request was made to approve CPT code 31255. As mentioned above, both OXHP medical directors determined that “The request was denied because limited ethmoidectomy is covered under CPT code 31254.” Without explanation, both medical directors, chose to ignore my doctor’s request, [HMO] guidelines and approved a partial ethmoidectomy, in lieu of a full ethmoidectomy.

Again, demand is made for [HMO] to adhere to its contractual agreement and approve the requested CPT codes 31240, 31255, 31256, 31276. It is cruel for [HMO] to willingly deny and delay coverage that they agreed to, I am entitled to and I paid for, while I suffer unnecessary pain and subject my sinuses to further damage.What is the name of your state?

 

[ecmst12]

It makes sense, but I can't comment as to your chances of success. Good luck!

Out of curiosity, what have your doctors said about the partial surgery? Do they think it would help you?

 

[lealea1005]

Your letter looks about as complete as you can be. Good luck.

Next time open season for health insurance comes up I suggest you try to switch to a PPO if you can. Let us know how you do with the letter.

 

[ammmum]

Out of curiosity, what have your doctors said about the partial surgery? Do they think it would help you?

Additionally, I have heart failure (because of some wierd affect, that a random virus had). It's not medically prudent (actually my cardiologist won't allow me) for me to have one surgery, with-a-wait-and-see-attitude for a second surgery. Plus my dr. heads two depts and Columbia University and is a teaching professor there. I thought that the flunky of a dr. that works for my HMO would have some respect for my dr, instead the HMO md just has a huge chip on his shoulder. I called the attorney general and they have agreed to submit my appeal to my HMO's legal dept. Hopefully, I will have all my paperwork together, by the end of this week.

 

[ecmst12]

I take it you already submitted your cardiologist's statement to the review board? That's not mentioned in the letter, you might want to include that too. If there's a medical reason that more conservative surgery is contraindicated, that's highly relevant to the request.

PPO's have pre-auth requirements for surgeries too. Most insurance companies have them, as a way of controlling costs, and I can't say I disagree with them in concept. In practice, the decisions don't always make medical sense, but that's why there are safeguards like appeals and even lawsuits to protect abuse from the insurance companies. But without some cost control, none of the companies would be able to stay in business, and that would be bad for everyone. At least until we get national healthcare - and even then I'm sure there will be cost controlling measures in place, otherwise taxes will have to increase out of control!

 

[ammmum]

I take it you already submitted your cardiologist's statement to the review board? That's not mentioned in the letter, you might want to include that too. If there's a medical reason that more conservative surgery is contraindicated, that's highly relevant to the request.

PPO's have pre-auth requirements for surgeries too. Most insurance companies have them, as a way of controlling costs, and I can't say I disagree with them in concept. In practice, the decisions don't always make medical sense, but that's why there are safeguards like appeals and even lawsuits to protect abuse from the insurance companies. But without some cost control, none of the companies would be able to stay in business, and that would be bad for everyone. At least until we get national healthcare - and even then I'm sure there will be cost controlling measures in place, otherwise taxes will have to increase out of control!

Thank you for the tip on getting the cardiologist's statement. I finally was able to gather all the info, fax and express mail in the might-as-well-have-been-the-term-paper-from-hell expedited second-level appeal. I couldn't keep track of all the letters, denials, guidelines, notes, receipts etc., so I went out and bought two covers and tabbed dividers. It was totally over-kill, but I don't want to give my HMO an excuse for an easy denial.

The more that I think of William W. McGuire and his stock options the more annoyed that I am getting. I am forced to wait in pain, until my surgery is approved. No consideration is considered for my ability to provide for my family, as the primary financial provider. Or the complications of my health, that include heart failure. Clearly, my HMO and their medical directors are not my friends. I am legally entitled to the the reasons and the clinical rationale for denials, but have not received them. So I'm wondering if it would be appropriate for me to send some-kind-of-a-final-version of the following letter to both Medical directors c/o my HMO, that denied my procedures. I plan a reporting both of them to the OPMC, and want as much ammo as possible.


Dear Dr. Denial:

According to New York State Public Health Law Article 44, Health Maintenance Organizations, the notice of determination should include detailed reasons for the determination and in cases where the determination has a clinical basis, the clinical rationale for the determination in clear and coherent language.

The letter written by the Senior Coordinator, HMO, dated XX.XX.XXXX, did not provide required detailed reasons for the determination, nor did the letter provide the required clinical rationale for the determination of CPT codes 11111, 22222, 33333, 44444. The Senior Coordinator stated that you were the Medical Director whom determined the medical necessity of the mentioned requested procedures.

Demand is made for clear written explanation, for the following:

* The reason and the clinical rationale of your determination to ignore my doctor’s request, and deny a full ethmoidectomy, and determine that a partial ethmoidectomy would be sufficient. CPT code 11111 nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior).
* the reason and the clinical rationale of your determination to authorize CPT code 22222 nasal/sinus endoscopy, surgical; with ethmoidectomy, partial (anterior).
* The reasons and the clinical rationale of your determination that my frontal and maxillary sinuses were clear during symptomatic period. Were my doctor’s notes, my physical symptoms, my MRI report citing opacification, my various antibiotic treatments and my dilated cardiomyopathy, with an estimated ejection fraction of 20% considered in your whole determination?

I am entitled to and expect expeditious specific answers to the above questions, so that I may plan my external appeal effectively.

Sincerely,

Patient-in-waiting

 

[ecmst12]

They haven't denied the 2nd appeal yet, right? Or have they?

 

[ammmum]

I just filed the second appeal last night. It took me awhile to gather my ENT and Cardio medical necessity letters. The original ENT letter, just stated that I had chronic sinusitis and that I needed a full endoscopy. I wanted him to add in the actual areas of my facial pain, so the MD would have a harder time denying the 2nd appeal. He also added in that he can't effectively clean the ethmoids without endoscoping the maxillaries and that a common reason for surgical failure is omitted endoscopy that was recommended.

My cardiologist's letter was kind-of-funny. She basically said knock-it-off.

 

[ecmst12]

Well it sounds like you have covered all your bases...good luck!

 

[ammmum]

My HMO has no shame. I filed an expedited second-level appeal, based on my HMO's crtieria explained in my first-level adverse denial....."a benefit determination determining urgent care is defined as a determination which, if subject to the standard appeal times, **************basically live or die...., OR in the opinion of a physician with knowledge of the Member's condition, would subject the Member to severe pain that cannot be adequately managed without the care or treatment that is the subject of the determination." So, my Dr. gave me a severe pain letter written exactly the way my HMO said. On Monday, I called to make sure that my HMO had everything. The HMO said that the expedited part did not qualify, 'cause it wasn't life or death and that my appeal would be under the standard time frames. I went up two supervisors, that wouldn't give last names, phone numbers or extensions, but basically told me tough, I didn't meet the criteria, that I couldn't speak to anybody, the appeal decision was final, and that the appeal department doesn't have phone numbers. I read the pain 'clause, until I was blue in my face.

I bothered the AG's office again, who also came back to me with the live or die answer, but then she finally read the pain clause and went back to my HMO. Her contact at my HMO had to go to her boss, who finally said I was right, and I received an answer yestrday afternoon that the Medical Director had overturned two CPT codes and was upholding the adverse decision on one CPT code, because both Sept's CT scan and Aug's MRI did not show sinusitis in that specific cavity.

I've sent off my external appeal tonight and I am hoping that the board realizes that it is now November and the tests that my HMO are clinging to are out-dated, and that maybe it would be medically prudent to look at all the evidence/information. That the CT scan scan failed to find significant sinus disease in any of my sinuses, including the one's that the Medical director overturned.

I am interested from a legal point, to see what the board determines. After going through this, I wonder if the guidelines really matter, or does my HMO have a shield behind EISRA to make their own medial determinations for medical necessity. And, I wonder if the job of the medical director is to make benefit determinations based on the established guidelines or can the medical director make his own medical determination of necessity and override all other medical recommendations, aka practicing medicine, without examining a patient, or making medical determinations by picking and choosing tests that benefit the HMO. Besides my own self-interest in having my surgery approved, I just find it interesting (and scary) to see the direction that HMO insurance is going, when the Medical Director gains financially on adverse determinations.

Does anybody know how long, before the "average" external appeal is determined?

 

[ammmum]

I won. I won. Yeah!!!!

After getting two of the three CPT codes overturned on my second-level appeal, I lost my external appeal on the last CPT code. I had the surgery anyway. My HMO paid for the approved CPT codes and I payed for the denied CPT code. The day after the surgery I filed on-line and sued my HMO in small claims court. My HMO did not show at court. I was told to prove my case. The first judge had to recuse herself, because she had the same HMO. The second judge ruled in my favor. I faxed in the judgment to my HMO. My HMO sent me a $4,000 check within 20-days and it cleared my account. Woo Hoo for me!

 

[lealea1005]

After getting two of the three CPT codes overturned on my second-level appeal, I lost my external appeal on the last CPT code. I had the surgery anyway. My HMO paid for the approved CPT codes and I payed for the denied CPT code. The day after the surgery I filed on-line and sued my HMO in small claims court. My HMO did not show at court. I was told to prove my case. The first judge had to recuse herself, because she had the same HMO. The second judge ruled in my favor. I faxed in the judgment to my HMO. My HMO sent me a $4,000 check within 20-days and it cleared my account. Woo Hoo for me!

Congratulations!!

 

[ecmst12]

That is awesome, I'm glad you won out in the end! Maybe they'll change their appeal policy in the future to avoid getting sued again...I'm sure it would have been cheaper to pay your surgeon a negotiated rate directly rather then having to reimburse you the full amount!