Q: My wife has been on an IV treatment for her Ankylosing Spondylitis for nearly 20 years now. As my career/insurance prov
My wife has been on an IV treatment for her Ankylosing Spondylitis for nearly 20 years now. As my career/insurance provider has changed, she always goes through the painful prior authorization process. We are now with Anthem Blue Cross and they saying that this IV treatment is not medically necessary despite Mayo submitting mounds of support that it is needed. She has not had the treatment since January, and her condition has deteriorated. Is there any action we can take against Anthem?
A:
A Minnesota attorney could advise best, as health care and insurance laws could be state-specific. But I'll try to provide a general response, in the hopes of helping you consider what direction you could consider taking to avoid further delays in your wife's care. I'm sorry for her ordeal.
The cheapest route could be to engage with the carrier to learn if further documentation would be helpful in re-evaluating the medical necessity of her needed treatment. These could include medical narratives, letters of necessity. This process could go on interminably, sometimes with a definitive outcome, sometimes not.
The quickest (not necessarily least expensive) could be to consult with a health care attorney with experience in challenging insurance denials. The options could be litigating the denial or filing for arbitration, depending on the provisions of the denial, the fine print on the back of denial and EOB, and any applicable forum selection clauses (for instance, using a court in a certain jurisdiction, or applying the laws of a certain jurisdiction)
Try to arrange a free initial consult with a Minnesota health care attorney with experience in contesting insurance claims - that could give you more definitive direction than my general response.
I hope you and your wife are able to arrange for her needed treatment. Good luck
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