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IC playing games
#1
Sad 
Hello,

So I've been receiving bimonthly facet injections on my right side. I've had 3 so far. Now the insurance company is challenging my next shot. I spoke with the IC nurse case manager and she told me this. Now I have to go visit the doctor in a week or two and, I am assuming, I have to make a case for why I need these shots. The doctor already knows that they help my right lower back and right leg very much. These shots work great on my pain and they want to stop doing them.
 
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#2
They love to play the games and try to get you to give up and save them money. If you have a lawyer let him earn his money. MY case manager has tried to stop them from doing anything and my doctor has said he will order what ever he thinks will help and not worry what they have to say. As long as he can justify the need he is not worried what they have to say
 
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#3
(04-08-2013, 05:28 PM)Manley2 Wrote: They love to play the games and try to get you to give up and save them money. If you have a lawyer let him earn his money. MY case manager has tried to stop them from doing anything and my doctor has said he will order what ever he thinks will help and not worry what they have to say. As long as he can justify the need he is not worried what they have to say

I was having an argument with the nurse case manager because she said that the EMG I had the other week showed no pinched nerves. She said that I don't have radiculopathy. I can't believe she said that. Can all of my pain be explained away by one EMG test? If they went by the MRI I would think they would have me jacked up on oxy by now. LOL I have no idea why they would cause all this trouble for a damn shot.

I called my doctor and they reassured me that they will stand by his recommendation.
 
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#4
generally if a state uses utilization review they have to have published guidelines and have to provide the doctor with a written denial and reason as well as an appeal process.
does your state allow utilization review?
I've never heard of a patient having to make the arguement for the protocols for a course of treatment.
Signature/Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information.........
 
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#5
(04-08-2013, 07:39 PM)1171 Wrote: generally if a state uses utilization review they have to have published guidelines and have to provide the doctor with a written denial and reason as well as an appeal process.
does your state allow utilization review?
I've never heard of a patient having to make the arguement for the protocols for a course of treatment.

I'm in Florida. I think the state allows reviews. Should I call the nurse case manager tomorrow and tell them that they need to send paperwork to my doctor (if he doesn't have it yet)? The field nurse case manager went ahead without notifying me and scheduled a doctor's appointment. I was waiting on a call on when I can come in for a facet injection.
 
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#6
Do you have a lawyer? If so talk with them if not it might be time to sit down and talk with a few. It's okay to deal with it if they are treating you and taking care of your needs but once they want to start denying treatment it's time to let a lawyer deal with them
 
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#7
(04-08-2013, 09:25 PM)Manley2 Wrote: Do you have a lawyer? If so talk with them if not it might be time to sit down and talk with a few. It's okay to deal with it if they are treating you and taking care of your needs but once they want to start denying treatment it's time to let a lawyer deal with them

I have a lawyer. His assistant asked me to get a written script by the MD that requests a right facet injection. She said if she got something in writing than she could work with the IC. They want me to do the legwork and convince this doctor that I need it. He's the one that requested it in the first place. I will see how it goes. The nurse case manager was some piece of work.
They're trying to convince my doctor that I don't need it. I asked the nurse case manager how much my pain is worth to her company.
 
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#8
If they asked you to get the script then do that and get it to your lawyer. He should use that to help you get the injection. Also I would ask your lawyer if they want you talking to the case manager. Trust me they are not your friend. I know it sounds like you know this from the way she is treating you but see what your lawyer says about talking with her.
 
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#9
One thing that might be being missed here is kind of a rule of thumb.. When it comes to injections 3 is the normal procedure and if there has been improvement then a possible rfa could be done.. You could say there helping but you cant keep getting them, for one the ins will start questioning and it can be bad for your health.. Usually a dr will write out a course treatment plan, and in fact a good ncm would be asking your dr for that..

As far as the emg, sometimes they can read false, as with a mri it may show some damage but doesn't mean that's where the pain is being generated from..
 
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#10
(04-08-2013, 09:04 PM)lonelylib81 Wrote:
(04-08-2013, 07:39 PM)1171 Wrote: generally if a state uses utilization review they have to have published guidelines and have to provide the doctor with a written denial and reason as well as an appeal process.
does your state allow utilization review?
I've never heard of a patient having to make the arguement for the protocols for a course of treatment.

I'm in Florida. I think the state allows reviews. Should I call the nurse case manager tomorrow and tell them that they need to send paperwork to my doctor (if he doesn't have it yet)? The field nurse case manager went ahead without notifying me and scheduled a doctor's appointment. I was waiting on a call on when I can come in for a facet injection.

for information on treatment denials:
http://www.myfloridacfo.com/WC/provider/index.html
Signature/Reminder :
........Each state has their own comp system; POST YOUR STATE to get accurate information.........
 
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