Janie, I sent the text to you in a Private Message on September 8th. Here it is again. I really want to emphasize that the CareFirst policy (linked to above) should also be given to your provider and submitted with the appeal - it's fantastic.
In Pennsylvania complaints are filed at http://www.insurance.pa.gov/Co...t/Pages/default.aspx
The Pennsylvania Insurance Department has a great FAQ at http://www.insurance.pa.gov/Co...InsuranceAppeals.pdf
Here is roughly what I wrote for my provider to use, which you'll have to adapt a bit. I suspect the last two paragraphs may be most useful to you. In my case the insurance company gave in after a couple of attempts through my state's Insurance Administration complaint process. Good luck!
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I am writing to request an expedited appeal (based on medical necessity) of your denial of Claim #xxxxx, following your denial of drug coverage for VSL #3 DS. I am Member # xxx. My group # is xxx. I am also requesting coverage for subsequent and ongoing use of VSL #3 DS.
My health has deteriorated markedly as a result of your refusal (beginning this year) to provide coverage. This claim is for the prescription-only medical food VSL #3 DS, which was denied for drug coverage at the pharmacy.
My J-pouch was created surgically in xxxx with a total colectomy after many years of intractable inflammatory bowel disease. It enabled me to resume an active life after years of severe illness. I developed chronic pouchitis, a common complication, in xxxx and it has persisted since then. Chronic pouchitis is the most common cause of pouch failure.[1] Pouch failure would be a personal disaster for me and an enormous expense for you, entailing a complex surgical procedure and a lengthy, risky recovery. Pouch failure is best prevented, both for good health care, sensible disease management, and prudent fiscal behavior.
VSL #3 DS is a well-studied mainstay for prevention and treatment of pouchitis[2],[3]. It is evidence-based, and uniformly recommended by J-pouch experts in the published literature. No well-studied satisfactory substitutes exist. VSL #3 DS has helped me considerably for about 5 years, albeit at maximal labeled doses, which retail for nearly $700/month. VSL #3 DS is available by prescription only at the recommended double-strength formulation.
I’ve reduced my dose of VSL #3 DS, because the full retail cost is unsustainable for an individual, but my health has suffered from the now-inadequate dose. I am trying desperately to avoid pouch failure. When adequately treated I enjoy a physically active, healthy lifestyle, working full-time and exercising regularly. When inadequately treated I have severe abdominal pain, diarrhea, and, most disabling, fecal incontinence. Please consider this appeal seriously. Adequate doses of VSL #3 DS will enable me to function properly, and will ultimately save you money.
[1] Shen B. Pouchitis: What Every Gastroenterologist Needs to Know. Clinical Gastroenterology and Hepatology. 2013; 11:1538-1549.
[2] Gionchetti P, Rizello F, Morselli C, et al. High dose probiotics for the treatment of active pouchitis. Dis Colon Rectum 2007; 50:2075-2084.
[3] Gionchetti P, Rizello F, Venturi A, et al. Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial. Gastroenterology 2000; 119:305-309.
