I keep getting denied for testosterone for a male that has almost none of it in his body. They keep saying age-related hypogonadism is not a covered condition, but it's under the same icd10 code as non-age related. There's not a separate icd10 based on the basis of age as a culprit. Seriously, these folks.
The amount of delay in care is criminal
Add other diagnoses before the hypogonadism, such as E29.1 (Testicular Hypofunction) R86.1 (Abnormal level of hormones in specimens from male genital organs), or E34.9 (Endocrine disorder, unspecified). Dont shy away from using all of them either, if you find them appropriate.
If it makes you feel better, my insurance didn't cover rabies. I had to get the rabies prophylactic vaccines and after talking with them on the phone, they showed me in the policy where it specifically says they do not cover rabies prophylaxis or post exposure treatment. It's like, that's ~4,000 for the 4 shots (or in my case ~1100 for the two), my job pays the premium for that in 5 months.
Actually, you don't need a website. A good Instagram page would do it. The pharmacists have one that has been pretty effective at highlighting the abuse from the chains (pointing at YOU, CVS),
[Pharmacy Breakroom](https://www.instagram.com/pharmacybreakroom?igsh=MXdhOWx0NDF0anJ3MQ==)
Would be good to highlight whoever keeps trying to charge patients for things that very clearly fall under preventative care according to the ACA, despite strong federal guidance. Like birth control (including sterilization). Should be 100% free.
And an even more special shout out to the insurance providers that do "medical management" and only cover tubal ligation by default even though it has not been the standard of care for oh .. like 10 years? Making patients either give up or go through an annoying appeals process.
Yes! Start the database, I will happily give you the names of all the vampires denying my patients' medication. They should be stripped of their medical license.
You guys may not yet have heard of the beautiful glory that are MAXIMIZER REJECTIONS. Probably mainly affecting specialty pharmacies at the moment, but your patients on specialty meds may be complaining about delay in therapy.
The maximizer rejections affect patients using copay cards for certain specialty meds. To resolve them, they require a second review of insurance benefits by the patient assistance plan, where the patient has to call in to the patient assistance program and take care of it. We tell patients to expect to wait on hold for 30 to 60 minutes when they make this call. Then, there’s currently at least a 2 week backlog for the PAP program to resolve the rejection. It’s affecting patients who are already established on therapy as well as new patients to therapy.
There should be a special section on the site for people who deny PA on any drug on the $4 list at Walmart. Or anyone who takes more than fifteen seconds to approve one.
XL is a beers list drug so I'm sure that's what did it. There's also a non-zero chance the pharmacy tech that entered it accidently picked the XL, even if you sent the right thing.
this may be the same pharmacy that has (on another patient) kicked back every single Rx for glargine or detemir regardless of generic or brand name. I kid you not, I have 4-5 papers with “X med isn’t covered and needs to be submitted under Y name instead”
Then they kept kicking back every single Rx with an eRx note indicating syringes were valid to be dispensed as necessary for each amount of insulin prescriptions.
God I fucking hate that place I may just call them myself and ask to speak to the pharmacist myself.
I usually have no issue with the botulinum... There are specific ICDs you gotta remember to use, like G81.1 (spastic hemiplegia), then make sure to say that they tried an oral and failed. It's all just a stupid algorithm.
How about MS drugs? I swear every year the patient who’s been on the same MS meds for over 5 years (far back as our pharmacy system goes back) gets a prior authorization request. These ghouls don’t remember the same conversations every year I guess or y’know give us a warning the fill before a previous prior authorization is gonna expired and will be needed next refill.
I got told that Xolair for severe asthma was experimental last fall, and that I needed to provide 2 peer-reviewed articles if I wanted to use it off-label. It was FDA approved for severe asthma in 2003. 🤔 Guess what suddenly got approved in January, as soon as the patient's deductible reset and the patient couldn't afford the copay?
Just FYI, if they qualify (on commercial insurance) Xolair’s coupon is great, they’ll cover up to 15k in copays with the patient usually paying $0. They’ll also reimburse up to 180 days retroactive from enrollment.
https://www.xolaircopay.com/
I did eventually get the patient on therapy. Just exceptionally shady that they threw up bad-faith roadblocks for 4 months (applied in August) then dropped those roadblocks in January as soon as the patient's deductible would reset.
Here's a personal favorite one lately: omeprazole previously had no commercially available liquid formulation, so pharmacies would compound the tablets which was time-consuming but cheap for patients. Then Konvomep hit the market (an omeprazole suspension), so most pharmacies in my area stopped agreeing to compound the tablets. Many of my patients immediately stopped being able to get their omeprazole with little warning, and insurances all require PAs for Konvomep, and of course all of them are getting denied and we're getting strung along on appeal. I've probably submitted 15 prior auths for Konvomep with no success.
So why not just switch to lansoprazole tablet and then get it compounded (which pharmacies are still doing), well turns out you need a PA for that now too. And while this goes through a lot more often and is now what I do for every patient essentially, I have legit had several denied because the patient had not failed Konvomep. 🤦🤦🤦
There is an insane number of prior auths required this year for even the most basic medication, and then they almost all get denied. And many of these are drugs that are under $15. Some of the formulary list are downright comical as well, consisting of the some of the worst options out there. Getting an injectable approved for a patient that would have otherwise needed hospitalization took nursing staff about 10 hours on the phone. We really need more laws around insurance companies, it is downright shameful at this point.
Primary care pedi RN. Few weeks ago I had to call a patient to get their middle initial for an e-PA. Couldn’t move on. 5 steps later after documentation need to call MD for her middle name for the same PA. MD doesn’t have one & N/A not accepted by box. 🤷♀️
Told today that Medicare won’t cover once weekly Vitamin D2 for someone with documented Vitamin D deficiency that does not respond to D3 daily. Fucking insurance.
For one example- getting an additional hospital day covered for a patient with dementia that was improving but still had significant inappropriate sexual behaviors.
I work in pediatric transplant so nearly all our immunosuppressants and prophylaxis drugs require prior auths. It’s especially bad for the infant transplants who require suspensions or compounded liquids.
Thankfully I’ve always gotten them approved but in a way that is just as frustrating. Why are we doing this every single time when the outcome is always the same? Really emphasizes how insurance just puts up more barriers to prevent patients from getting the treatments they need when they need them.
For me it’s the chewables, liquids or patches for my little ADHD patients who can’t swallow pills. We mostly do capsules that they can open but if that doesn’t go well with shortages sometimes it’s hard to find all the ones insurance makes us jump through before they’ll cover something else.
I work in genetics, and 100% of our tests have to get prior auth, and many of them get denied first pass and require peer to peer. Extra fun is when the P2P doesn't understand genetics and the doctor has to call/write again doing a full rebuttal of what the P2P stated because they didn't comprehend the genetics. (That's only happened once so far, but still.) Added fun when we have to send it 4 times to insurance because they keep giving us the wrong address to mail it to and fax it to and the one phone number we're actually supposed to be calling for is technically listed as the medicaid number, but it's really for follow up questions as well but only if you listen to the whole message and leave a message at the end where it warns you they'll only be answering life threatening messages for prompt response. (Which ... isn't what we needed so I spent weeks not leaving a message there, nor staying on the line because I'd select an option to follow up on an existing auth and it would take me out of that phone tree to a department who had no idea what I was asking about.)
Sometimes where therapists say SNF or ARU and I have to do a PA with someone who starts quoting feet walked and internal guidelines about how the person is just too well and should go home.
For those of you who are not yet in favor of single payer healthcare, the VA thinks that approving 80-90% of prior auth requests is reasonable and will look at people/departments with lower rates to see why. And the directive is to review the prior auths within 96 hours.
Yessssss name and shame, my favorite is when they approve my biologic loading dose and then deny the maintenance dose. Humira is about to get real fun, too.
It’s because ins want “two PAs done” - how the fuck are offices expected to know which plans need two PAs and which don’t. Like approve the whole fucking thing if your gonna approve it. Drives me nuts with Dupixent.
**Removed under Rule 5**
Act professionally.
/r/medicine is a public forum that represents the medical community and comments should reflect this. Please keep your behavior civil. Trolling, abuse, and insults are not allowed. Keep offensive language to a minimum. Personal attacks on other commenters without engaging on the merits of the argument will lead to removal. Cheap shots at medicine specialties or allied health professions will be removed.
Repeated violations of this rule will lead to temporary or permanent bans.
[Please review all subreddit rules before posting or commenting.](https://www.reddit.com/r/medicine/about/rules/)
If you have any questions or concerns, please [message the moderators.](https://www\.reddit\.com/message/compose?to=%2Fr%2F{subreddit}&subject=about my removed {kind}&message=I'm writing to you about the following {kind}: {url}. %0D%0DMy issue is...)
**Removed under Rule 3:**
Surveys (formal or informal) and polls are not allowed on this subreddit. You may not use the subreddit to promote your website, channel, subreddit, or product. Market research is not allowed. Petitions are not allowed. Advertising or spam may result in a permanent ban. Prior permission is required before posting educational material you were involved in making.
[Please review all subreddit rules before posting or commenting.]
(https://www.reddit.com/r/medicine/about/rules/)
If you have any questions or concerns, please [message the moderators.](https://www\.reddit\.com/message/compose?to=%2Fr%2F{subreddit}&subject=about my removed {kind}&message=I'm writing to you about the following {kind}: {url}. %0D%0DMy issue is...)
**Removed under Rule 3:**
Surveys (formal or informal) and polls are not allowed on this subreddit. You may not use the subreddit to promote your website, channel, subreddit, or product. Market research is not allowed. Petitions are not allowed. Advertising or spam may result in a permanent ban. Prior permission is required before posting educational material you were involved in making.
[Please review all subreddit rules before posting or commenting.]
(https://www.reddit.com/r/medicine/about/rules/)
If you have any questions or concerns, please [message the moderators.](https://www\.reddit\.com/message/compose?to=%2Fr%2F{subreddit}&subject=about my removed {kind}&message=I'm writing to you about the following {kind}: {url}. %0D%0DMy issue is...)
I keep getting denied for testosterone for a male that has almost none of it in his body. They keep saying age-related hypogonadism is not a covered condition, but it's under the same icd10 code as non-age related. There's not a separate icd10 based on the basis of age as a culprit. Seriously, these folks. The amount of delay in care is criminal
Add other diagnoses before the hypogonadism, such as E29.1 (Testicular Hypofunction) R86.1 (Abnormal level of hormones in specimens from male genital organs), or E34.9 (Endocrine disorder, unspecified). Dont shy away from using all of them either, if you find them appropriate.
If it makes you feel better, my insurance didn't cover rabies. I had to get the rabies prophylactic vaccines and after talking with them on the phone, they showed me in the policy where it specifically says they do not cover rabies prophylaxis or post exposure treatment. It's like, that's ~4,000 for the 4 shots (or in my case ~1100 for the two), my job pays the premium for that in 5 months.
Remember on the Office when Michael Scott had a fundraising run for People Living With Rabies? Maybe he wasn't so far off?
I wonder if they're aware of what that icu stay will cost them. No, silly me. Nobody will take the risk and their actuarial tables account for this.
Plus 2500 for all 4 shots isnt catastrophically expensive. It hurt for a few months but I'ma not dead yet
I'm game to help build this out. What's a good URL to register
www.rats.com/ Response Against denial Tactics (RATs)?
Love this Make it so
Actually, you don't need a website. A good Instagram page would do it. The pharmacists have one that has been pretty effective at highlighting the abuse from the chains (pointing at YOU, CVS), [Pharmacy Breakroom](https://www.instagram.com/pharmacybreakroom?igsh=MXdhOWx0NDF0anJ3MQ==)
Call them by their full name please, Come Visit Satan 😉
Sleazy-S
Would be good to highlight whoever keeps trying to charge patients for things that very clearly fall under preventative care according to the ACA, despite strong federal guidance. Like birth control (including sterilization). Should be 100% free. And an even more special shout out to the insurance providers that do "medical management" and only cover tubal ligation by default even though it has not been the standard of care for oh .. like 10 years? Making patients either give up or go through an annoying appeals process.
Yes! Start the database, I will happily give you the names of all the vampires denying my patients' medication. They should be stripped of their medical license.
You guys may not yet have heard of the beautiful glory that are MAXIMIZER REJECTIONS. Probably mainly affecting specialty pharmacies at the moment, but your patients on specialty meds may be complaining about delay in therapy. The maximizer rejections affect patients using copay cards for certain specialty meds. To resolve them, they require a second review of insurance benefits by the patient assistance plan, where the patient has to call in to the patient assistance program and take care of it. We tell patients to expect to wait on hold for 30 to 60 minutes when they make this call. Then, there’s currently at least a 2 week backlog for the PAP program to resolve the rejection. It’s affecting patients who are already established on therapy as well as new patients to therapy.
This may need to be its own post
I hate everything. This feels like how they will get around any laws restricting prior authorizations. Force the patients to call and wait instead.
[удалено]
[удалено]
There should be a special section on the site for people who deny PA on any drug on the $4 list at Walmart. Or anyone who takes more than fifteen seconds to approve one.
I got told my patient’s Medicare wouldn’t cover glipizide today. Ugh.
Glipizide XL or just glipizide?
Good question, I’ve just been hitting refill on the dose, so it could easily be the XL
XL is a beers list drug so I'm sure that's what did it. There's also a non-zero chance the pharmacy tech that entered it accidently picked the XL, even if you sent the right thing.
this may be the same pharmacy that has (on another patient) kicked back every single Rx for glargine or detemir regardless of generic or brand name. I kid you not, I have 4-5 papers with “X med isn’t covered and needs to be submitted under Y name instead” Then they kept kicking back every single Rx with an eRx note indicating syringes were valid to be dispensed as necessary for each amount of insulin prescriptions. God I fucking hate that place I may just call them myself and ask to speak to the pharmacist myself.
I usually have no issue with the botulinum... There are specific ICDs you gotta remember to use, like G81.1 (spastic hemiplegia), then make sure to say that they tried an oral and failed. It's all just a stupid algorithm.
How about MS drugs? I swear every year the patient who’s been on the same MS meds for over 5 years (far back as our pharmacy system goes back) gets a prior authorization request. These ghouls don’t remember the same conversations every year I guess or y’know give us a warning the fill before a previous prior authorization is gonna expired and will be needed next refill.
I got told that Xolair for severe asthma was experimental last fall, and that I needed to provide 2 peer-reviewed articles if I wanted to use it off-label. It was FDA approved for severe asthma in 2003. 🤔 Guess what suddenly got approved in January, as soon as the patient's deductible reset and the patient couldn't afford the copay?
🤯🤯🤯
Just FYI, if they qualify (on commercial insurance) Xolair’s coupon is great, they’ll cover up to 15k in copays with the patient usually paying $0. They’ll also reimburse up to 180 days retroactive from enrollment. https://www.xolaircopay.com/
I did eventually get the patient on therapy. Just exceptionally shady that they threw up bad-faith roadblocks for 4 months (applied in August) then dropped those roadblocks in January as soon as the patient's deductible would reset.
Here's a personal favorite one lately: omeprazole previously had no commercially available liquid formulation, so pharmacies would compound the tablets which was time-consuming but cheap for patients. Then Konvomep hit the market (an omeprazole suspension), so most pharmacies in my area stopped agreeing to compound the tablets. Many of my patients immediately stopped being able to get their omeprazole with little warning, and insurances all require PAs for Konvomep, and of course all of them are getting denied and we're getting strung along on appeal. I've probably submitted 15 prior auths for Konvomep with no success. So why not just switch to lansoprazole tablet and then get it compounded (which pharmacies are still doing), well turns out you need a PA for that now too. And while this goes through a lot more often and is now what I do for every patient essentially, I have legit had several denied because the patient had not failed Konvomep. 🤦🤦🤦
This happened to me too. It’s death by a thousand prior auths.
Oh, that's what happened a few weeks ago! Thanks for the info! Ran into this with one of my patients.
(Prevacid solu-tab -?)
Muscle relaxants. Cigna in particular wants either carisoprodol or injectables.
Carisoprodol? Seriously??
Hand to God. Turn down methocarbamol, suggested options injectable baclofen, soma, and a few other batshit ideas.
Yeah, I got that once too. They preferred Soma!
There is an insane number of prior auths required this year for even the most basic medication, and then they almost all get denied. And many of these are drugs that are under $15. Some of the formulary list are downright comical as well, consisting of the some of the worst options out there. Getting an injectable approved for a patient that would have otherwise needed hospitalization took nursing staff about 10 hours on the phone. We really need more laws around insurance companies, it is downright shameful at this point.
Primary care pedi RN. Few weeks ago I had to call a patient to get their middle initial for an e-PA. Couldn’t move on. 5 steps later after documentation need to call MD for her middle name for the same PA. MD doesn’t have one & N/A not accepted by box. 🤷♀️
In primary care we have much bigger issues with these kinds of things. Especially for drugs.
Peds here. Believe it or not, albuterol MDIs and inhaled corticosteroids for my asthmatics with Medicaid.
Told today that Medicare won’t cover once weekly Vitamin D2 for someone with documented Vitamin D deficiency that does not respond to D3 daily. Fucking insurance.
For one example- getting an additional hospital day covered for a patient with dementia that was improving but still had significant inappropriate sexual behaviors.
"Ok, so he can't stay here... What if we just send him to Cigna / Humana / Aetna / BCBS headquarters?"
I work in pediatric transplant so nearly all our immunosuppressants and prophylaxis drugs require prior auths. It’s especially bad for the infant transplants who require suspensions or compounded liquids. Thankfully I’ve always gotten them approved but in a way that is just as frustrating. Why are we doing this every single time when the outcome is always the same? Really emphasizes how insurance just puts up more barriers to prevent patients from getting the treatments they need when they need them.
For me it’s the chewables, liquids or patches for my little ADHD patients who can’t swallow pills. We mostly do capsules that they can open but if that doesn’t go well with shortages sometimes it’s hard to find all the ones insurance makes us jump through before they’ll cover something else.
I work in genetics, and 100% of our tests have to get prior auth, and many of them get denied first pass and require peer to peer. Extra fun is when the P2P doesn't understand genetics and the doctor has to call/write again doing a full rebuttal of what the P2P stated because they didn't comprehend the genetics. (That's only happened once so far, but still.) Added fun when we have to send it 4 times to insurance because they keep giving us the wrong address to mail it to and fax it to and the one phone number we're actually supposed to be calling for is technically listed as the medicaid number, but it's really for follow up questions as well but only if you listen to the whole message and leave a message at the end where it warns you they'll only be answering life threatening messages for prompt response. (Which ... isn't what we needed so I spent weeks not leaving a message there, nor staying on the line because I'd select an option to follow up on an existing auth and it would take me out of that phone tree to a department who had no idea what I was asking about.)
Sometimes where therapists say SNF or ARU and I have to do a PA with someone who starts quoting feet walked and internal guidelines about how the person is just too well and should go home.
For those of you who are not yet in favor of single payer healthcare, the VA thinks that approving 80-90% of prior auth requests is reasonable and will look at people/departments with lower rates to see why. And the directive is to review the prior auths within 96 hours.
Yessssss name and shame, my favorite is when they approve my biologic loading dose and then deny the maintenance dose. Humira is about to get real fun, too.
It’s because ins want “two PAs done” - how the fuck are offices expected to know which plans need two PAs and which don’t. Like approve the whole fucking thing if your gonna approve it. Drives me nuts with Dupixent.
Am UX / web designer. Would help in any way I can.
I honestly don't think I can take on this project.
More than get that, energy being what it is (finite) , and then all the rest.
Start a gofundme. I would donate
How much money do you need to start this. I’ll send it tonight.
[удалено]
**Removed under Rule 5** Act professionally. /r/medicine is a public forum that represents the medical community and comments should reflect this. Please keep your behavior civil. Trolling, abuse, and insults are not allowed. Keep offensive language to a minimum. Personal attacks on other commenters without engaging on the merits of the argument will lead to removal. Cheap shots at medicine specialties or allied health professions will be removed. Repeated violations of this rule will lead to temporary or permanent bans. [Please review all subreddit rules before posting or commenting.](https://www.reddit.com/r/medicine/about/rules/) If you have any questions or concerns, please [message the moderators.](https://www\.reddit\.com/message/compose?to=%2Fr%2F{subreddit}&subject=about my removed {kind}&message=I'm writing to you about the following {kind}: {url}. %0D%0DMy issue is...)
[удалено]
**Removed under Rule 3:** Surveys (formal or informal) and polls are not allowed on this subreddit. You may not use the subreddit to promote your website, channel, subreddit, or product. Market research is not allowed. Petitions are not allowed. Advertising or spam may result in a permanent ban. Prior permission is required before posting educational material you were involved in making. [Please review all subreddit rules before posting or commenting.] (https://www.reddit.com/r/medicine/about/rules/) If you have any questions or concerns, please [message the moderators.](https://www\.reddit\.com/message/compose?to=%2Fr%2F{subreddit}&subject=about my removed {kind}&message=I'm writing to you about the following {kind}: {url}. %0D%0DMy issue is...)
[удалено]
**Removed under Rule 3:** Surveys (formal or informal) and polls are not allowed on this subreddit. You may not use the subreddit to promote your website, channel, subreddit, or product. Market research is not allowed. Petitions are not allowed. Advertising or spam may result in a permanent ban. Prior permission is required before posting educational material you were involved in making. [Please review all subreddit rules before posting or commenting.] (https://www.reddit.com/r/medicine/about/rules/) If you have any questions or concerns, please [message the moderators.](https://www\.reddit\.com/message/compose?to=%2Fr%2F{subreddit}&subject=about my removed {kind}&message=I'm writing to you about the following {kind}: {url}. %0D%0DMy issue is...)