WC insurer denies RX

[maxpane]

What is the name of your state (only U.S. law)? Nebr.
What can I do when a perscription is denied by wc insurer? The rx was written by my pain management dr. I have paid out of pocket for this medication for 2 months and it has had nothing but positive results. Can they actually do this? I believe the decision to be cost driven.
Thanks,

 

[Ladyback1]

What is the name of your state (only U.S. law)? Nebr.
What can I do when a perscription is denied by wc insurer? The rx was written by my pain management dr. I have paid out of pocket for this medication for 2 months and it has had nothing but positive results. Can they actually do this? I believe the decision to be cost driven.
Thanks,

How old is your claim?
What is your diagnosis?

What other modalities for pain have been tried? What other medications have been tried for pain?

Have you ASKED your claims adjuster/examiner why they are denying it?

 

[maxpane]

Claim is 7 years old. I have been diagnosed with failed back surgery syndrome. I have been on most of the opiates and still on a few. I have a spinal cord stimulator now. Marinol was denied "because of the nature of the drug". The medicine helps me in ways the others dont.

Thanks for your response.

 

[Proserpina]

Claim is 7 years old. I have been diagnosed with failed back surgery syndrome. I have been on most of the opiates and still on a few. I have a spinal cord stimulator now. Marinol was denied "because of the nature of the drug". The medicine helps me in ways the others dont.

Thanks for your response.

If you're referring to them declining to pay for Marinol, I doubt there's a court in the land going to penalize them for it.

 

[Ladyback1]

Claim is 7 years old. I have been diagnosed with failed back surgery syndrome. I have been on most of the opiates and still on a few. I have a spinal cord stimulator now. Marinol was denied "because of the nature of the drug". The medicine helps me in ways the others dont.

Thanks for your response.

Yes, they can and will continue to deny it. It is not a "recognized" treatment for pain.
It's not driven by the cost. Even in states that have legalized marijuana and/or medicinal marijuana, most insurance, will not cover it.

 

[Ladyback1]

Came back to add:

With the denial for this medication, the insurer has created a "dispute". If you were so inclined, you could attempt to negotiate a disputed settlement with the insurer. A disputed settlement usually means that the insurer pays a sum of money for you to "go away" and they close your claim (or they can close a portion of your claim). With that settlement money, you would be free to pursue whatever course of treatment you choose--even non-traditional treatments, like marijuana.

If that is an avenue you are interested in pursuing, PLEASE seek the advice of an attorney who is well-versed in Nebraska work comp law. Settlements can have a lot of pitfalls and loopholes, including but not limited to: Medicare Set Aside (MSA), future and current indemnity/disability benefits, whether you qualify for SSDI, etc.

However, depending on how much of a struggle and hassle the insurer has caused in your getting specific medical care, vocational rehab and return to work, settling out the claim could provide you with some peace.

After 7 years, and with your diagnosis, it may be worth your time to consult with a Work Comp Atty. and see if a disputed settlement is an option. If you continue to be covered by Workers' Comp insurance, they will continue to be able to put up roadblocks in your medical treatment of choice.

(I have 5+ yrs as a work comp examiner. And regardless of my personal thoughts/opinions of what constituted a valid medical practice, medication or treatment, I would not, could not be able to authorize certain things...which was difficult seeing as how I live in a state that recognizes medical marijuana.)

 

[Dave1952]

I wonder if the OP could better explain the Marinol. The OP has a "bad back" and takes opiates. Opiates may cause nausea and vomiting. Marinol does seem appropriate therefore but it's really pricey. I presume that Reglan, Zofran et c. were already tried. Why is the insurer refusing to pay for Marinol?

 

[Ladyback1]

I wonder if the OP could better explain the Marinol. The OP has a "bad back" and takes opiates. Opiates may cause nausea and vomiting. Marinol does seem appropriate therefore but it's really pricey. I presume that Reglan, Zofran et c. were already tried. Why is the insurer refusing to pay for Marinol?

And why is the insurer denying? Oh, that's simple: If they approve synthetic THC for one claimant, that opens the door for every other claimant. And if synthetic THC can be authorized, then the door opens wider for natural THC to be authorized. Even living in a state where Med. Marijuana is legal and legitimized, it is not approved by the Dept. of Labor & Industry (who governs Work Comp here) as a legitimate treatment for workers' compensation claimants. Meaning, even if a Dr. prescribes it, the work comp insurer will not and does not have to pay for it.

Marinol is FDA approved for use w/ nausea and vomiting in CANCER patients. It, to my knowledge, is not approved for use as an adjunct therapy for pain, and pain related symptoms.

Most, if not all states, use either ODG or ACOEM as guidelines for "acceptable" treatments, drugs, modalities, etc. as it relates to workers' compensation. To the best of my knowledge, neither ODG or ACOEM recognizes or recommends the use of THC or synthetic THC as a valid treatment option or alternative for failed back syndrome. FWIW: Pain is NOT a diagnosis, pain is a symptom. Medical records have to reflect objective medical findings to support any diagnosis (especially when talking workers' compensation). Pain is purely subjective. What causes me pain, and my tolerance to pain will not be the same for anyone else, and vice verse. The OP could request a utilization review of the doctors prescribed medication. However, since most states follow ODG or ACOEM as their approved treatment "Bible", Marinol will not be approved.
(http://worklossdatainstitute.verioiponly.com/ : select drug formulary, then scroll down for the list of drugs, and there will either be a yes or no on the right hand side. Marinol and Cannabis/Marijuana are a big fat NO)

Plus, no insurer/Third Party administrator, want to run afoul of the federal government. So, the insurers/TPAs, take a hardline stance on THC/synthetic THC.

Even less controversial drugs that have proven "off label" usage won't be approved, because of the ODG/ACOEM's guidelines. It took forever (it seems) for certain anti-epilepsy drugs to be OK'd for use in patients who had nerve damage and/or chronic muscle spasms due to an injury. Another example: Botox injections have been shown to decrease migraines/headaches that are associated with cervical, head and sometimes shoulder injuries. But, getting that passed the insurance companies has been a battle. Simply because, it is seen as an off label usage. However, in the past few years, it is becoming a little easier.

 

[maxpane]

Ladyback1, thank you for your time and detailed responses, they are very much appreciated as is this site. For the record I read Marinol enhances opiates and is why I got my dr. to prescribe it. As it turns out after I took it I got the best sleep in 7 years. With back injury you toss and turn all night. When I take marinol before bed the next thing I hear is my alarmclock. Those 7 - 8 repositions at night either dont happen or I dont remember them. Better yet the next day I feel better and dont need hydrocodone as a rescue med. Some mornings I even forget to turn my SCS on. I havent been able to reduce my morphine intake yet which is the goal. Im not saying Marinol relieves pain but i believe a good nights sleep can, at least it does for me. My dr says the insurer is even trying to discourage him from writing the script. Thats just bad business no matter how you look at it. Work comp wont approve it but my own insurance did.

 

[OHRoadwarrior]

Take sleeping pills. That is what I take with my opiates.

 

[cbg]

Good luck getting your own insurance to pay for anything you're claiming is work related.

 

[Ladyback1]

Take sleeping pills. That is what I take with my opiates.

Depending on why you can't sleep, sleeping pills may or may not help.

Marinol/THC works on a couple of different areas which allows for a better night's sleep. The people I have spoken with state that the sleeping pills can cause a fog/hangover the next morning, whereas THC does not seem to.

And cbg is correct, if it is documented that the THC/Marinol is being prescribed as a result of a work related injury/diagnosis, they will most likely deny it.

Good luck, OP. This particular issue is going to be difficult to convince an industry (insurance) that is medically helpful/necessary.