Insurance asking for "Medical Necessity" for IVIg treatments

Bryan, I had Anthem… I dumped them. They were OK when they were just Blue Cross, but after the merger, they went downhill and became less compassionate and more money hungry.

My experience with Anthem is that each different claims adjuster (and they have thousands) has his/her own feelings about how they should approach claims approval. Perhaps they have internal quotas for saving the company money and it’s that time of the month when their bonuses are on the line? Maybe it’s the new employee syndrome where newbie’s want to show their bosses that they play the game in the company’s favor?

Whatever the reason, Anthem is probably the most inconsistent insurer I’ve dealt with when it comes to processing claims. Seemingly randomly, and out of the blue, claims that had been approved in the past are denied for some undisclosed reason hidden behind the words “medical necessity”. What you must do is to call their 800 number and go thru their red-tape phone system (designed to annoy us and discourage future calls). Get hold of a live person and get all the details behind what happened that caused the denial. Find out if those same criteria will be applied on subsequent treatments.

Armed with the technical details, ask the person you are talking with to process a grievance on your behalf. Your options are described here: https://www.anthem.com/shop/appealsandgrievances

They will tell you if they need your doctor to process a grievance or if you can do it. Tell them that if the grievance is rejected you will file a complaint with your state department of insurance. I had to do that with Anthem twice. I won both complaints.

Since the forums search function hasn’t worked for several months, here are some links to other threads that discuss insurance company denials and offer some suggestions for dealing with them:

Negative Spinal Tap-Still CIDP?

Denied/Delayed ivIG

I wish you the best of luck with treatment and hope you prevail against Anthem.

I had no difficulty getting IvIg. It is a standard treatment for GBS and CIDP. I expect they did require some support for the diagnosis, but I didn’t hear about it. I had Blue Shield of California HMO plan.

Insurers want to know how the diagnosis was made because IvIg is not only expensive, it is scarce. It is not helpful for everything, so it shouldn’t be wasted when it is not an appropriate treatment. Some insurance companies are more difficult than others on matters like this, however.

I also have had trouble with Anthem. 12/16 they approved me for 6 months. I had to switch from a PPO to HMO 1/17 and they denied me for 7 weeks before approving me again for 6 months. Now I’m at the point of trying to continue and they denied me again. I’m fairly confident it will work out, it will just involve my neuro doing a “peer to peer” with an Anthem physician claims person.

Bryan, how have things worked out? I just finished my first 6 months of approved ivig infusions every 2 weeks. I told the neuro that I thought I should stay on the every 2 week plan given my state of Soto she and he agreed. I have Aetna through my work. I was on the HMO plan but upped my enrollment to the POS plan to have more options without needing referrals in my medical future. I was very pleased to receive my Aetna letter the other day saying I was approved for the next 6 months of infusions every 2 weeks. Just hoping that the day will come when I may be like chirpy birds and only need maintenance doses. Right now, my cidp is very unpredictable but at the same time manageable. Let us know how things are turning out for you and best of luck. Jeff in Houston.