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Re: [IP] Sorta OT but kinda relevant



>     > Respectfully, I disagree. If a doctor prescribes a >pump and
>     writes a
> letter of medical necessity, the >insurance company can not
> contravene the doctors >
> >order .... that's called "practicing medicine"
> 
>     According to what I now understand about my HMO when my doctor
> recommends any type of treatment for a disease it is open for review
> by insurance company doctors to decide whether agree with the PCP's
> assessment of being appropriate and of medical necessity. So, even
> though my PCP may say pump therapy is the best way to go the
> reviewing doctors for the insurance company could say that MDI is
> better for me.

It is a delaying tactic. Without having seen you or reviewing your 
medical history, no doctor can decide a course of treatment. Also, 
there is a difference between a doctors "recommendation" and a 
prescription + letter of medical necessity. Once you have the latter, 
it becomes very difficult for any other physician to contravene the 
order without overwhelming evidence that it is not good treatment. 
Since all the recent scientific studies conclude for the most part 
the CSII is superior in some way or another to MDI, that would be a 
very difficult thing to show. 

> Of course a battle of wills and evidence will ensue
> if that happens, but it is a worst case scenario.
> 

Unfortunately, it is all to common. But, go forward with the 
knowledge that those that have walked this path before you have won 
the battle.

Michael

> >. . . Be persistent, and when and if denied at the final >appeal level,
> file a  complaint with your state's insurance >commissioner. . .
> 
> 
>     I do believe almost any insurance company will relent if the
>     matter is
> pursued, and I intend to pursue it to the ends of the earth.
> However, just with the stroke of a pen they can say no. Then I have
> to prove my side while they prove theirs and I wait for the pump. I
> am not expecting this but it is a possibility.
>     I believe that the reason that not one in the history of
> Insulin-Pumpers.org has been denied is only because IP is here to
> let people know to fight. I wanted a pump years ago and they told me
> no (Different insurance) I didn't fight it because I thought they
> had the last word.
> 
> Cody S. Alderson
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