EPO coverage denied because I don't have severe anemia?

[swramsay]

Hmmm. I just got a letter from my insurance company denying my nephrologists request for EPO. They state:
" Epogen is a medication for the treatment of severe anemia associated with certain conditions. Because we cannot establish that you have been diagnosed with severe anemia, we are unable to approve coverage of epogen."

What's that all about?

[Wallyz]

What's that all about?

Dickweeds with Business degrees telling your doctor how to treat you.


You need a blood test with low hemoglobin and a letter from your doctor that indicates that dialysis patients lose x% of blood to dialysis everymonth.

[jbeany]

It may be some standard form they send to anyone trying to get something that expensive.  What it means is that you get to waste time, effort and money on getting them to approve the request for something you need.  The letter or some part of your coverage paperwork should have the steps you need to take to protest the decision.  It's going to be a time consuming pain in the butt. 

Here's the big stick - you're gonna need it!

 

[paul.karen]

This is the future of universal healthcare.

I agree with WallyZ 100%  It is some suit with little if any medical background denying people medicine due mainly to the cost.

This is how other countries with Universal healthcare systems keep costs down.  By denying people certain medications due soley on the cost of the medicine.  This is a major reason Canada has over a 16% higher death rate on cancer and other severe illness patients.  Sure the visits may be free but they cut corners where ever they can.

[monrein]

This is the future of universal healthcare.

I agree with WallyZ 100%  It is some suit with little if any medical background denying people medicine due mainly to the cost.

This is how other countries with Universal healthcare systems keep costs down.  By denying people certain medications due soley on the cost of the medicine.  This is a major reason Canada has over a 16% higher death rate on cancer and other severe illness patients.  Sure the visits may be free but they cut corners where ever they can.

This has not been my experience of the Canadian system Paul.  Not even a little bit.

Here is a link to some studies that have compared outcomes of different health issues between our two countries.  You will see that wait times for some surgeries are longer here and that can be frustrating but to say that they cut corners wherever they can is not in fact accurate.  I do think that with fantastic insurance in the US, the medical care is outstanding.  However, many people fall between the cracks through no fault of their own and Canada has a very different philosophy about medicine than does the US.  Costs are an issue here (and there BTW) and no system is perfect but I think that you are mistaken and perhaps have some misperceptions or incorrect assumptions about the Canadian system.  I have heard many times from Americans that Canadians are told which doctors they can see.  I have no idea where this idea came from but it isn't true.  I choose my family doctor who refers me to specialists but if I have a preferred specialist, she'll refer me there.  There are many things that could be improved on here for sure and from all my time spent within the system I could personally suggest several improvements and indeed ways to save money.
In Canada, like in the US, the system is also variable and what happens in a big city may be quite different in a smaller community and may also vary from province to province.  I have been involved with this system in a very chronic way for a long time now and with all due respect Paul, I think that you do not know very well that of which you speak with such confidence.

http://www.pnhp.org/single_payer_resources/CAN_Comparison_Sheet.pdf

Here is Wikipedia's comparison, although I'm not suggesting that Wiki is any kind of absolute authority.
http://en.wikipedia.org/wiki/Canadian_and_American_health_care_systems_compared

[Wallyz]

More than that Paul, the issue is that EPO is a standard treatment for people on dialysis, and it is this individual company that is bucking the trend, in single payer systems, the problem is new treatments getting approved, you don't get denied for standard treatments.

[paul.karen]

Im Sorry Monrein.

I read an article just today in the Trentonian ( a local neespaper) with facts and stats that is where i got that number.

I am Canadian and all my family live in Canada.  I also never heard of being told what doctor you have to go to.
And im not knocking your system it is good for everyone.  But it wouldn't be like that here it would be much worse.
Obama is putting no planing into this plan.  Money up front and make a plan later this is his M/O on many of his plans.
He wants a bill on his desk by July.
I am 100% for healthcare reform in many different ways.  I am not into Universal healthcare.  I am not into working hard to
give people who choose not to do the same a free ride be it for housing medical free college on and on.
I feel disabled and certain other people for a variety of reasons should be covered and i think they are.  Children should be covered and ANYONE who holds a job should be covered be it at burgerking or cutting grass.  Call it a PERK instead of universal.

I think mainly monrein i dont have faith in this government on either side of the isle  to run anything well.
I fear we wouldnt have your standards but more along the lines of the standards of Cuba or the likes.  Although Michael Moore likes there medical system.

Sorry Swramsay i hope they can get you sorted out on the medicine.

[dialysisbiller]

Hmmm. I just got a letter from my insurance company denying my nephrologists request for EPO. They state:
" Epogen is a medication for the treatment of severe anemia associated with certain conditions. Because we cannot establish that you have been diagnosed with severe anemia, we are unable to approve coverage of epogen."

What's that all about?

the doctor has to state that is why you would be given EPO..... it's a messed up thing.... the insurance industry looks at the HCT (HGBx3) to determine approval of EPO.... our Insurance Verification reps call ins companies all day long with referals/authorizations for EPO.... i'm surprised the doctor didn't put it in the orders for your treatment... there are a few ways people get EPO for my centers, the doctor gives a prescription and they get it filled at a pharmacy or they have it administered during treatment or during their clinic visit it is picked up from the center so it can be administered at home for home patients.

Medicare requires a diagnosis code specifically for reimbursement for EPO 285.21 (severe anemia and this is associated with EPO only)... without this code, it will not be paid.  Iron Sucrose(venofer) has another code associated with anemia. (280.9)