Hello everyone, I've thought long and hard on whether or not to post this but when I hear so many being denied ketamine infusion treatment by their insurance, I cringe a little inside each time. I am going to share with you what I used to fight a denial by my insurance company; this may or may not help you, I sure hope it does and that is my only intention, to help. All this info was gathered off the web and put together for my insurance company, after which I was approved. I cannot guarantee this will work for you nor do I want to start a debate, this is only what has worked for me, and I hope it will help you to.
I would like to appeal a recent decision. My name is __________ and I have RSD/CRPS in ________________, which continues to worsen. I have had this for almost __ years now. My doctor and I requested that I be treated by __________________ using therapeutic intravenous ketamine infusion. With me having this condition for as long as I have, I have had many treatment therapies that have not helped. Ketamine infusion therapy has. Dr. ___________ cost for this treatment which includes the surgery center is _____________ for a 4 hour infusion.
The reason given for denial I was given was because Dr. _________ does not contract with your health plan and that I should find and seek a doctor that does. I have been to ________ doctors contracted in your plan, none are able to provide me with the treatment I need. I have called every pain specialist/anesthelogist that we could find in-network, and in the state of ___________, and can not find one that do these infusions.
Other treatment therapies used for RSD are:
SGB - $1400.00 per block
LGB- $5000.00 per block
Spinal cord stimulator- $57,000
Pain pump implant - $30,000 - $35,000 with refill running a monthly cost of anywhere from $200 - $300.
The first two are blocks and are usually given within the first 6 months of RSD and are only effective short term, and only a certain number of them can be given.
The spinal cord stimulator is used if you have a trial and it works or helps, then they proceed to implant it. I have had the trial by one of the top RSD doctors in ______________ and it did not work.
I had the pain pump implanted and after a year and a half, the doctor and I agreed it was time to remove it as it was not reaching/helping both upper and lower extremities. I suppose I could try the pain pump again but I would have to have two of them to reach all effected areas and then worry when I will need a liver transplant as the medicine will effect my liver.
I ask that you reconsider because after all the treatments mentioned above and all the medicines I have been on and tried, ketamine therapy has been the one that has helped. I do not wish to be on daily narcotics, again with concerns not only to my quality of life, but my liver. I first started infusions in ___________, going every 3 weeks for low dose infusion therapy. I then found Dr. ____________ who offered a higher dose which I did. I could not believe the difference it had made in my life, and in my pain.
Thank you for your time and consideration,
I also included the following documents with the above
On January 13, 2009, the New York State Attorney General Office published a 24- page* report concluding:
“The current industry model for reimbursing out-of-network care is fraudulent. The industry uses a conflict-laden database riddled with errors at the expense of the consumer.
The database is neither independent nor fair. This leads to chronically flawed decisions. Given the heavy burden of health care costs that working families must bear when insurers fail to pay what they owe, the out-of-network system must be fixed”.
Click here for the Attorney General's HEALTH CARE REPORT
On July 24, 2008,*Health Net Inc.*was ordered to pay $255 million to settle out-of-network underpayment allegations. Health Net insures 3.9 milliom members in New Jersey, New York, Connecticut, and on the West Coast, through several health insurance subsidiaries. The investigation found that some insurance companies "dramatically" under-reimbursed their members for out-of-network medical expenses. As a result, New York state Attorney General Andrew M. Cuomo issued 16 subpoenas to the largest insurers in the country, including Aetna, Cigna, and Empire BlueCross BlueShield.
On January 15, 2009, UnitedHealth, one of the largest health insurance companies in the United States, agreed to shell out $350 million to settle lawsuits that claimed the company shortchanged consumers and physicians when paying for medical services outside its preferred network.
The settlement would provide for payments to doctors who claimed they were underpaid and patients who said their plan didn’t cover enough of their out-of-network care. An independent third party will figure out who gets what.
*Aetna announced its own deal with the New York State Attorney General Office. The company will stop using a database developed by Ingenix Inc. (a company controlled by United health) to determine out-of-network pay and will kick in $20 million to help fund the independent third party.
WHAT TO DO IF YOUR INSURER PAYS LESS THAN YOU THINK IS FAIR
1. You have the right to appeal. Read your insurance materials and the notice from your insurer, called an explanation of benefits. It will explain how to appeal.
2. If you live or work in New York, the Attorney General’s Office may be able to assist you by advocating for you with your insurer.*Click here to file a complaint
3. If you do not live or work in New York, contact your local Attorney General’s Office for assistance.
Click here for the contact information for the State Attorney General for your state. You want to speak to a lawyer in the Consumer Fraud Division.
Here are some suggestions / talking points regarding reimbursement from insurance carriers for treatment with intravenous (IV) ketamine.
Treatment of breakthrough pain due to RSD / CRPS is an accepted treatment by all insurance companies.
For over 30 years, treatment of breakthrough pain with IV ketamine at doses up to and including those doses required for general anesthesia has been approved by the Food & Drug Administration (FDA).
Ketamine is approved as a “general anesthetic". Anesthesiologists, therefore, are most qualified to use the drug. For more than three decades, anesthesiologists have used ketamine to treat breakthrough pain in numerous clinical situations because of its unique properties.
¶ Breakthrough pain during dressing changes in burn victims (where intubation is not required because ketamine is a mild respiratory stimulant)
¶ Breakthrough pain during procedures in children (where no IV required because ketamine can be given IM)
¶ Breakthrough pain in asthmatics (where ketamine is a bronchodilator)
¶ Breakthrough pain in wounded soldiers (where ketamine supports blood pressure)
¶ Breakthrough pain in patients with RSD / CRPS (where ketamine uniquely inhibits the excitatory neuropeptide responsible neuropathic pain called glutamate and avoids the serious complications associated with the use of opioids - narcotics - to treat breakthrough pain).
**Two well-controlled studies demonstrate the long-tem benefits of outpatient ketamine infusions
Therefore, insurance companies are obligated to reimburse patients for customary and usual cost for the treatment of breakthrough pain with IV ketamine without further delay pursuant to PPO contracts.
Click here for supporting documentation by experts in the field stating that IV ketamine is the ideal medication for breakthrough pain in patients with RSD / CRPS
Ketamine is being used at the dose and route of administration as approved by the FDA to treat and control pain due to RSD / CRPS. Some insurance companies might try to argue that the FDA did NOT approve ketamine to treat RSD / CRPS. However, the FDA gave no specific medical condition / disease state as an indication for the drug. No medication has ever been approved by the FDA specifically to treat RSD / CRPS. Yet insurance companies routinely cover most medications to treat this neurological disorder.“Off-label” use of drugs is common in the USA and Canada.
In January 2009, the Canadian Government recognized escalating doses of IV ketamine on an outpatient basis as a treatment for RSD / CRPS.
Timothy Lubenow, MD
Anthony Kirkpatrick, MD, PhD
University of South Florida
Barry Friedberg, MD
University of Southern California
Los Angeles, California
*TREATMENT WITH KETAMINE:
Ketamine infusions have been reported to be safe and efficacious for the management of refractory complex regional pain syndromes (CRPS) in both the inpatient**and outpatient**settings. This therapeutic intervention can be especially helpful in the emergency room setting where large doses of narcotics (opioids) are often injected to control pain. The problem with narcotics is that huge doses are required because the neuropathic pain caused by CRPS is relatively resistant to the pain-relieving effects of narcotics. The use of narcotics often leads to hospitalization of the patient due to prolonged heavy sedation and respiratory depression. In addition, chronic use of narcotics leads to physical dependency, tolerance and constipation.
In contrast, ketamine has a very selective effect on relieving pain due to CRPS without causing prolonged sedation and respiratory depression. Therefore, ketamine is less likely to lead to lengthy and expensive hospitalizations. There is no problem with physical dependency, tolerance or constipation with ketamine.
In addition, ketamine "booster" infusions have proven effective in patients with severe, multiple extremity, intractable, CRPS. Most of these patients have failed all reasonable treatment options for CRPS. Ketamine booster infusions are likely to lead to fewer emergency room visits for these extremely difficult and serious cases of CRPS. The FDA-approved drug insert supports the safety ketamine:
"Ketamine has a wide margin of safety; several instances of unintentional administration of overdoses of ketamine (up to ten times that usually required) have been followed by prolonged but complete recovery.”**
The merits of using ketamine over narcotics to treat CRPS were presented at an international symposium held at the University of South Florida
The 2009 Coders' Desk Reference lists the following CPT codes for "Therapeutic Intravenous Infusions"
96365 - first hour
96366-*each additional hour.
1. USA DIAGNOSTIC CODES:
337.21 - Reflex sympathetic dystrophy of the upper limb
337.22 - Reflex sympathetic dystrophy of the lower limb
337.20 - Reflex sympathetic dystrophy NOS ( my doctor uses this for full body)
2. USA "PLACE OF SERVICE" CODE:
Surgery Facility: ___________________
___________________ ( address)
___________________ ( phone #)
3. Dr. _______________: ______________________ insert your doctor’s license number here.
Okay, that's what I used to fight my denial and I was then approved. I gathered all this information off the web, put it together with my appeal and sent it in. Maybe I was lucky but maybe just maybe they seen that this was the most cost effective treatment, I'm not sure, but it worked
Hope this helps someone,