Great job coming up with the policy information. That is the key document, as it dictates the legal rights and obligations of the parties. I think you are on the right track; this may simply be a paperwork issue, or perhaps a mistakenly entered ICD 9 diagnostic code. It may now just be a situation of dotting the i’s and crossing the t’s in order to get the coverage back in place.:)
I am not licensed to practice in North Carolina and not familiar with North Carolina law. I can tell you that insurance benefits are provided pursuant to your insurance “plan”, and that plan is generally considered a contract under the law. From that portion of the denial you quoted, it sounds like the insurer is now taking the position that it has insufficient documentation regarding your initial diagnosis requiring IVIG. That being the case, you may simply need to provide that documentation to the insurer in order to reinstate coverage for your IVIG. Be prepared to jump through whatever hoops you have to in order to get the coverage you need. It will be worth it in the end.
Your insurance plan is the contract that dictates what the insurer must cover. If you don’t already have a copy of that entire plan, get one immediately. You can contact the insurer and inquire as to what exactly it needs in order to reinstate coverage. Use the contact telephone number on the back of your insurance card. Keep meticulous written records of EVERY communication with representatives of the insurer, including time of day, date, identity of the representative, and substance of the conversation. Blue Cross/Blue Shield has case managers assigned to a lot of people with chronic conditions who get expensive treatments like IVIG. Here in Pennsylvania, my IVIG treatment is considered a “shock” (expensive) claim for BC/BS, and believe me, they keep track of my treatment. You can ask to speak to your case manager, or have one appointed. It helps if you can deal with one individual who knows your case. Confirm everything in writing.
You will also need your doctor’s help here, not only to provide the necessary documentation, but if necessary to advocate for you with the insurer. My doctors went to the mat for me with BC/BS when it refused to cover my Lyrica, and we got it approved.
If you are not getting anywhere with BC/BS directly you have a number of other options. You can contact your state insurance commissioner in North Carolina and ask for assistance and/or file a complaint. You can retain counsel to represent you. I recommend you retain someone familiar with insurance benefit issues, perhaps an attorney who handles disability cases or an elder law attorney. I understand there are now businesses that specialize in dealing with health benefit issues on behalf of insureds such as yourself; perhaps you can locate one in your area by using the Yellow Pages or the internet. Your state insurance commissioner’s office may also be able to provide help finding one as well.
It seems totally inconsistent to me that Blue Cross/Blue Shield essentially is now taking the position that it never had documentation your INITIAL diagnosis required IVIG treatment, yet covered that treatment for a number of years prior to issuing a denial. Something is fishy here. Keep us advised.