INSURANCE APPROVAL . . . . NOT!

Fortunately, most of this has been handled by the doctor and his staff.  This is what I know.  They filed with our prescription insurance coverage, CVS Caremark.  CVS Caremark denied the request on 9/21 because Carter's bone age test results showed that his bone development is not delayed.  I received the official letter of denial from the insurance company in the mail Friday.  Our doctor sent in the appeal letter earlier in the week, so I decided to call the claims department and find out the status of the appeal.  

They also denied the appeal on 9/27, which is frustrating.  I did, however, get some information about the channels these things go through.

When the initial request is received it's reviewed and if all of the criteria aren't met it's automatically denied.  An appeal is filed and goes to the first level appeals department.  Once again, if all the criteria aren't met, it's automatically denied. When the third request/second appeal is sent in it goes to the second level appeals department.  This is where they are able to take other things into consideration and they have the power to override the criteria qualifications and make a decision based on ALL of the information received, not just their list of criteria.  Really?  What. A. Waste. Of. TIME!

I'm not getting my panties in a bunch just yet, though.  I still feel like it's all going to work out.  It's just their process, albeit an asinine process.  No wonder they have to charge so much for insurance, they're paying three departments worth of employees to do ONE JOB . . . . three times!  

Nope, not going to let this get me down.  We knew from the beginning this can be difficult and that our insurance is not one of the easiest companies to deal with.  The medication costs between $2,000 - $3,000 per month, so it only makes sense for them to be careful who they're dishing it out to.

When I spoke with the rep. at CVS Caremark, I specifically asked what happens if he's denied a third time.  She said that is usually the final say.  Then I went on to explain that since he's producing little or no growth hormone, it's just a matter of time before his bone age will be behind.  Are we supposed to just wait until that happens?  It seems silly to do that since we know without a doubt it will eventually happen.  She said those are the things that we need to send in our letter for the second appeal.  

I'm hoping to hear something this week.  When I spoke to the doctor on Friday, they hadn't received the notification of the second denial.  Once they receive that, a new letter, along with all the info will be sent again.  When CVS receives it, the turnaround is usually 48-72 hours.  So, we should know something by the end of this week or beginning of next week.