Question
QUESTION: I am legally disabled with genetic (degenerative) inflammatory disease(s)...After a decade of successful yearly prior authorizations for 'the ONLY' medication that allows me to achieve any quality of life, I was recently denied the latest prior approval. My current provider/prescribing physician has been my doctor for 1 year, as my previous doctor retired this time last year. I was told by a Medicaid prior authorization manager that the prior authorization request form had been changed within the last year in an effort to make patients use generic, lower cost medications and had my doctor answered 'yes' on the question: 'if I had been prescribed a generic/similar medication and documented it unsuccessful', then the prior authorization would have been approved. There is 'NO generic' available for the medication (as it was pulled from the market) and I HAVE TRIED other 'similar medications in years past without success. I desperately need this particular medication in order to function in any productive manner and have filed for an appeal. Any advice you can offer regarding winning my appeal would be greatly appreciated, as I will certainly be hospitalized without it due to my condition and the degenerative nature of my disease. Thank you & Kindest Regards...T~
ANSWER: Hi Tod
That is a tough appeal.
See if the doctor will file a new form.
Try and document the removal of the Generic.
But most important is a strong letter from the doctor that your specific drug is the only known on that can help your condition and there is no known generic.
Lots of luck
John.
---------- FOLLOW-UP ----------
QUESTION: Are you familiar with the Medicaid appeals process (as far as the procedures involved)? Although I only have (1) 'prescribing physician', I also see my primary care doctor (who is quite aware of my condition)as well as an orthopedic specialist...would it be advantageous to supply letters from these sources stating the severity of my condition?...Medicaid 'did NOT' send me 'anything' regarding the denial or my right to appeal it, I only found out about it because I had a scheduled appointment and the doctor stated 'I' should have received this information as well as the denial form. I had to find a person at Medicaid who was familiar with the 'prior authorization' area and ask her to fax the forms to me so I could file the appeal within the 30 day required period, otherwise I would not even have known about it at all.
I have been on this medication for over a decade without incident and always successful prior approval. It doesn't seem 'right' that they could just decide to no longer authorize it for me, especially since the specialist have decided it it the correct medication for me.
I would like to know more about the 'appeals process' and really 'what to expect and any addtl. info, etc. that might help my appeal for a successful outcome.
Thank you again for your time and assistance with this matter.
T~
Answer
Hi again.
The problem with which we have to consider is that the regulations in each State may have differences. So in general.
You receive a denial from Medicare. The denial is supposed to have:
Reason for the denial
which part of the regulation the denial is based upon
Name and phone number of the case worker and supervisor
When and how to make an appeal
If you fail to meet the when and how part, the appeal is lost.
Next, in the appeal, you have to attack the reason for the denial. Go to the State web site, click on the Medicaid area, click on manuals. search for the PAM or PEM that they cited for the denial, and make sure it is a proper denial. Get documentation to support you position and weaken theirs. this is the only Medicine, trial of others have failed, we had prior authorization, the doctor signed the wrong form, etc. Your own doctor is your strongest ally.
If you get a second denial, immediately appeal it. Hope this is some help.
John
