Tennessee The request does not meet the definition of Medical Necessity

[Appalachia]

Jurisdiction

Tennessee

I have a serious issue with my new Healthcare Insurance. My work changed this year on July 1st, 2023 from Cigna to BCBSNC. I work from home in TN, but my employers are in NC. When my Neurologist sent in the prescription for my Migraine Medication (Nurtec), they were denied. Explanation not on denial is: " The request does not meet the definition of Medical Necessity found in the benefits booklet ". So my Doctor said let's try Emagality.

Let me pause here for a minute. I suffer from migraines for over 20 ++ years. I have been on triptans for most of that time without them doing anything for my pain. In 2019, I had a week-long migraine attack that ended up almost in the hospital after my blood pressure was so high I just about had a stroke. That said I was put aimovig. I did not have a good reaction to the medication. Next, I was put on Topomax and Nurrtec. The Nurtec was like a miracle medication. Not only did I get relieved, I got my life back. I was not worried about going to an event or vacation and staying in bed for three days because of my migraines. I could work without having so much pain I could not concentrate or even talk.

Anyway, I am not on Topomax anymore, because it caused me some kidney issues, but the Nurtec still was working as a preventative and immediate relief. Now, I have been trying for three months Emgality without any backup. The migraines I get are like I used to have, unbearable. Also, the injection is painful and hurts for days after the shot. I told my doctor I wanted to get back onto my Nurte. He sent in another request.

Again, I got denied the same response from the Insurance company, and they want me to try another Injection medication. I do not want any Injections. I want to take pills I can control daily or when the pain comes. No more Injections. They do nothing for me. I have been on Nurtec for three years, and I should not suffer in pain and agony while BCBSNC tells me this medication is unnecessary.

What can I do? How can I fight this? I need help. Please advise Thank you

 

[cbg]

It is VERY common, when there's been a change in your insurance, for the new carrier to have a different formulary of approved medications than you previously had. IN GENERAL, because I cannot guarantee without seeing your policy, they will be agreeable to your remaining on your existing medication with medical information from your doctor.

You will have to go through their formal appeals process, which will be described in the documentation you received with the decline. Your doctor will need to provide your medical history, including what you've tried in the past and what the medical results have been. It may take some time - it won't be an overnight solution. But in my experience, and I have a lot of it, you should eventually be able to return to your prior medications.

If you have your insurance through your employer, you may be able to get some help from your employer's HR or Benefits office (that's what I do) but you'll have to go through the formal appeal process no matter what.

 

[Appalachia]

It is VERY common, when there's been a change in your insurance, for the new carrier to have a different formulary of approved medications than you previously had. IN GENERAL, because I cannot guarantee without seeing your policy, they will be agreeable to your remaining on your existing medication with medical information from your doctor..........

Thank you for your response.

I have information on how to appeal. They offer two options: a Letter or send in an Appeal Form they supply online. What would you recommend I should do?

I will also reach out to HR. Thank you for that information. On top of that, I will inform my Doctor of my next steps and ask him to provide any documentation that would be helpful.

Thank you

 

[adjusterjack]

They offer two options: a Letter or send in an Appeal Form they supply online. What would you recommend I should do?

Personally, I recommend the online form. avoids mailing time. Just make sure you take screen shots of every step in the process and save them to your computer.

Meantime, you can pay for the medication yourself and perhaps get reimbursed later. I know it's expensive but there are ways to get discounts and financial help. There may also be similar medications in pill form that you haven't tried yet.

Study the following resources carefully.

nurtec cost at DuckDuckGo

 

[cbg]

Personally, I recommend using the online form with a letter from your doctor attached.

 

[army judge]

Medically Necessary or Medical Necessity described for Tennesseans:

"Medically Necessary" are procedures, treatments, supplies, devices, equipment, facilities or drugs (all services) that a medical practitioner, exercising prudent clinical judgment, would provide to a member for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

in accordance with generally accepted standards of medical practice; and

clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the member's illness, injury or disease; and

not primarily for the convenience of the member, physician or other health care provider; and

not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that member's illness, injury or disease.

For these purposes, "generally accepted standards of medical practice" means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors.

NOTE: For TennCare purposes, Medical Necessity and Medically Necessary are defined by Public Necessity Rules of the Tennessee Department of Finance and Administration, Bureau of TennCare, Chapter 1200-13-16 Medical Necessity.

This document has been classified as public information.

///////////////////////////////++++++++++++++++++++++++++++

Medical necessity described:

"Medical necessity" is difficult to define, with as many different interpretations as there are payers; however, most definitions incorporate the idea that healthcare services must be "reasonable and necessary" or "appropriate," given a patient's condition and the current standards of clinical practice. Yet typically, the decision as to whether services are medically necessary is made someone who has never seen the patient.
Medicare defines "medical necessity" as services or items reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. CMS has the power under the Social Security Act to determine, on a case-by-case basis, if the method of treating a patient is reasonable and necessary. For all payors and insurance plans, even if a service is reasonable and necessary, coverage may be limited if the service is provided more frequently than allowed under a national coverage policy, a local medical policy, or a clinically accepted standard of practice.

Claims for services deemed to be not medically necessary will be denied. Further, if Medicare (or any other payer) pay for services that they later determine to be not medically necessary, they may demand that those payments be refunded (with interest). If a pattern of such claims can be established, and the provider knows or should know that the services reported were not medically necessary, the provider may face monetary penalties, exclusion from Medicare program, and criminal prosecution.

Most payers use claim edits (automated denial/review commands) to review claims. These edits ensure that payment is made for specific procedure codes when provided for a patient with a specific diagnosis code or predetermined range of ICD-10-CM codes. ICD-10-CM codes should support medical necessity for any services reported. Diagnosis codes identify the medical necessity of services provided by describing the circumstances of the patient's condition.

To better support medical necessity for services reported, you should apply the following principles:

1. List the principal diagnosis, condition, problem, or other reason for the medical service or procedure.

2. Assign the code to the highest level of specificity.

3. For office and/or outpatient services, never use a "rule-out" statement (a suspected but not confirmed diagnosis); a clerical error could permanently tag a patient with a condition that does not exist. Code symptoms, if no definitive diagnosis is yet determined, instead of using rule-out statements.

4. Be specific in describing the patient's condition, illness, or disease.

5. Distinguish between acute and chronic conditions, when appropriate.

6. Identify the acute condition of an emergency situation; e.g., coma, loss of consciousness, or hemorrhage.

7. Identify chronic complaints, or secondary diagnoses, only when treatment is provided or when they impact the overall management of the patient's care.

8. Identify how injuries occur.

All of the above information must be substantiated in the patient's medical record, which should be available to payers, on request.

https://www.aapc.com/blog/46500-medical-necessity-why-it-matters-ways-to-demonstrate-it/
....

 

[justblue]

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[Redemptionman]

Yeah I have encountered some issues with certain medications being covered. Many compound pharmacies offer coupons or discounts on name brand prescriptions which have no generics. In some cases it is cheaper than insurance.

have you looked at Nurtec one source? A lot of times if you get the medication from a dedicated pharmacy or get huge coupons then you do not have to pay the crazy prices of some high priced medication.

Savings and Support | Nurtec® ODT (rimegepant)

good luck with it.