Advocate forYouself

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Sometimes the patient advocates for himself. Recently I had a sugery rejected by blue cross insurance.And, this surgery (described below) was rejected after a similar surgery was done already,and approved. There are certain inaccuracies in this letter, e.g. Dr B did not plan to do exactly the same type of surgery, he was going to do a trabelectomy. Dr. X wanted to repeat the surgery he did in my right eye, by perfoming the same procedure in my left eye. The insurance company rejected the second surgery, In general my doc has been running into problems with Approvals, and he wanted to know what the hell I said to them to get approval. And so I showed him. He wanted other patients to model something like it, to argue for approval. I think he is right to argue this, and to teach patients to do it, he's concerned for this particular surgery, as, it is not very "experimental" at least not in a bizzare sense. It is a mechanical drain, as a opposed to a simple hole. A shunt is not an exotic insturment. He wanted a letter to show patients how to argue for it. So that the hospital is helped by the acceptance of the surgery, and more patients are helped. Insurers can be headaches sometimes, but Blue Cross seemed to respond well to my argument.

Essentially their rejection letter made no real sense to me. And so I wanted them to hear the sense in having the surgery, I thought they didn't really have the whole idea, so I explained it to them, and that is pretty much all I did.And, so I wrote them what I thought was a reasonable letter, expecting reasonableness from them, and I got it. Blue Cross is probably the best insurance there is. And, so I was fairly confident that they'd see my point of view.

They responded very quickly. Which suggests that medical insurers might respond very well to reasonable arguments...without assuming your intent is litigious. And they should not assume that. I gave my doc a copy to show his patients.
Here is a copy of what I said: The surgery was approved, and both surgeries were successful.


To: Grievance Committee
BCB.
Regarding case number: 9xxy8186JJZ00
refusal of OS surgery: Trabeculectomy Express Shunt
for refractory glaucoma.
Gary Stone

Proposed by Dr. X, Glaucoma Surgen, Hospital


You have rejected approval of surgery to my left eye, that was proposed by doctor x, stating, essentially that 'medical management is sufficien' to treat my glaucoma. .
However, records from Dr. G, Opthamologist, Salem Mass (see url below) since 2008
were submitted to Dr. B of OCBoston (Boston Hospital) in 2009. These should have convinced you that medical management had failed.. Dr B concurred with Dr. G....

The surgery proposed then, and pre approved then - was identical to the surgery done to the right eye by Dr X of MEE ( which I assume was preapproved also?)

..Dr B also recommened surgery for the left eye - but booked surgery to the right first because vision was severely deteriorated. He wanted to preserve the vision I had, and slow the progression of the disease, to prevent complete blindness. If there is a variation in this currently proposed surgery, I believe

it only involves a shunt, to hold open the flap for drainage. This would improve the duration of the drainaige systems. Standard trabeculectomy can close up in one year's time. I am not exactly sure but I think Dr B proposed the same idea.

. I believe surgery to the right eye was pre-approved based on the argument that medical
management had failed. But it was not done at that time in 2009. (See reasons why, below)

Dr. G sent documentation of the difficulty of standard medical management to Dr. B, showing him that I had developed severe allergy to: Alphagan, Lumagen, Cosopt, and Timoptic...and, versions of each with different preservatives. The reaction involved the conjunctiva, and all tissue of the upper lid, as well as fatty tissue beneath the lower lid. The swelling was extreme/ severe, sometimes resulting in near closure of the eyelid, add to that severe itch with drainage. I acquired allergies to most of these drops,

some produced instant reactions, in particular, Timoptic. cosopt was a delayed and acquired allergy, which is unfortunate, as it worked very well to drop pressure.

My eyes are so sensitized to all of the standard drops, that the reaction is currently instantaneous...and that can be demonstrated if need be. These drops produce a fairly spontaneous reaction, from one

exposure of each, The swelling required steroid drop treatment, which, as you are aware, produces increased IOP.

You should have records of tests done at OCB from 2009. And records for payment of those tests, as well as the rational for referal (standard treatments are complicated) and you should have records of coverages for standard drops, and alternate drops, from Dr. G)

You should have records of surgery proposals from Dr B.
As well as all records of visits and prescriptions from to Dr. G's office circa 2008 - 2009.

Dr B did all of the standard tests that Dr X did prior to the recent right eye surgery: from visual field tests, direct exam, and optic nerve density tests. These tests that demonstrated severe damage done to both eyes by this disease. Dr B diagnosed me as "legally blind" on my first visit. He recommended social

security disabilty immediately and advocated for it. Social Security provided very quick approval.I am currently on disability based on his evaluations .
.
Dr B's conclusion was that this surgery was mandatory because Xalactan, the only drop
that did not produce allergy, failed to keep the pressures in both eyes sufficiently low. The average pressure on Xalactan was 20- 30, but pressures were variable on the higher side, some pressures were in the 40's or higher (consult your records on pressure history) Bellows also said laser surgery was

contraindicated, as the disease was too advanced. (diagnosed too late) Laser is an early stage treatment.I went for the surgery with Dr B, but I did not bring an es court...in 2009
and he sent me home without surgery because an es-court was required..

. I could not get an escort, and I assumed other arrangements could be made, a cab could take me home, etc. This was not acceptable. Dt anesthesia effects and the need to for a low stress post op experience, normal walking to a train, or significant distance, is not part of the post op recommendation. there are activity restrictions.

I am refering to Dr. B's recommended surgery to (OD) in 2009 and it was booked, pre-approved, but not done in 2009. Again, his plan was to do the right eye, and then the left. at a later date. Dr X's plan was identical in sequence.

But, Dr B and Dr X must have got prior approval which was apparently not consulted or researched during your review, and may I have resulted in your decision to reject the proposed surgery to OS I am also wondering if you have consulted all of my Opthamologists records, Dr B's records, and Dr. X's records.Perhaps this info needs to be aggregated in one place, as the history would be less confused.
and it would show, Dr.X is not recommending anything exceptional. The shunt procedure is not new either, many doctors are doing this surgery, as it tends to hold the draniage hold open longer I was lax in getting back to the issue of surgery after Dr B, reasons below)

In 2009 B said said that the left eye had to be done. When I canceled another appt for surgery, he sent me a letter, stating that if the surgery was not done, I would go from being legally blind to totally blind.

He dropped me as a patient for not being able to coordinate a sugery date when I would have reliable transport. I think he was trying to force the issue by emphasizing the seriousness of my condition.

Dr, G did the same, and reiterated that this surgery needed to be done droppped me as a patient and wrote a similar letter, and recommended Dr X of MEE.

He sugggested seeing Dr. X immediately which again, I was lax in doing, until I found out
that Dr G would no longer fill my eye drop. Xalactan. I believe G was forcing the surgery issue as well, but refusal to fill the drop. I went to MEE emergency room, and they gave me more Xalactan and set up an apt with Dr. X.

I did she Dr. X. at the end of this summer, and he expressed the same opinion as Dr. B. As a side note:Perhaps the insurance companies should consult with surgeons and understand what they mean by "failure of medical management" and perhaps they can also define under what conditions this type of surgery is urgently needed, this way, perhaps, the surgery would seem less exotic. From my case,it should be obvious, that allergy to drops, the undesirable effects of Diamox, and potential danger of that drug, with advanced disease - make the surgery mandatory.

Dr X simply reiterated what both doctors had said. The surgery to the eye OD needed to be done soon to save the right eye, and it was done last month, and it was successful. I've had no complications in the right eye, and my vision actually seems slightly improved in the right eye. The pressures are now normal 8-10, ideal for profusion.

I am assuming too, that my surgery to the right eye was "pre-approved" as I assumed B surgery was, in 2009. .
And, so - I am puzzled as to why the surgery OS, has come under question. Perhaps it is because when Diamox was added by Dr X, the pressures were low, prior to surgery.

May I remind you of several things: Diamox is a dangerous
drug, Xalactan plus Diamox is not standard medical management.
In fact, Dr G only gave me one dose of Diamox, in 2008, with drops, when he first diagnosed me. He did it to drop pressure rapidly as, on diagnosis in 2008, the presures were 52 OS and 56 OD. Your records should support those facts.

Dr X gave me daily doses, running up to the surgery but, only to keep the pressures low
prior to the surgery. One the most undesirable side effects Diamox are blood dyscrasias (aplastic anemia, and other but there are many other negative effects including increased risk of calcium oxalate kidney stones, etc. Please consult untoward Diamox effects profile.

I cannot take Diamox now, in any case, as the pressure in the right eye post op was 1, and adding Diamox now - would drop pressures in right eye dangerously low, while preserving the left eye from further damage You might find these pressures in the post op records.

(The cause of low pressures post op in the right eye was slow or, variable healing, as there was no leak, we are hoping the presure will be in range by my December 2 my next f/u visit.)

I will try to aggregate all relevant records on from G (2008-2009) and B (2009) to rationalize
trabeculectomy with shunt for the left eye. Although, i believe you should have this info already. If you do not have these records please let me know, and I will contact Dr G.

I am scheduled to see Dr X, December 2 and I will discuss this matter with him.
Meanwhile please consult the 2009 rationals submitted
to your company.I believe should contained your records
from Dr. G and Dr B... as well that proposal sent by
Dr. RB MD
50 Staniford Street Suite 600 OCB
Boston , MA - 02114
617-367-4800
Here is doctor G's info:
Dr. G info:
http://www.healthgrades.com/directory (url sample)_search/physician/profiles/dr-md-reports/cccczzzc
Please contact me if you need more information from me, but be aware of two things,

Dr X and Dr B not making frivolous recommendations.,.Secondly,
for the second surgery, there is a time concern. Pressures in the left eye were high on last visit and Diamox cannot be used...becuse of low pressures in the right eye (it is a centrally acting pill that would affect both eyes), post op and because of and allergy to drops, the staging of disease (and the impracticality of laser at this stage)
It appears OS surgery recommendation arguments are as strong for the left eye. As strong as they were
for the right eye. This is an awkward problem not being able to adequately treat pressures in the left eye, without harming the right eye. This surgery is therefore urgently needed..Please see any records pertaining to allergy, provided by Dr B used to rationaize 2009 surgery.
Please refer hx of allergic reactions to standard drops, the allergic reactions to those
same drops using different preservatives, et.al

I will try to aggregate all of those records with MEE (current hospital), so that a single case can be made for OS surgery. This, so that all records are available to you. Then the logic will be clear. But, they should have been available to you, when Dr. B made his argument for surgery in 2009. And when the surgery to the right eye was apparently approved in September 2010.

May I remind you, that both Dr. X and Dr B are foremost in the field of Glaucoma surgery,and they would not recommend this surgery if it was not entirely neccessary to save my eyesight - which is currently very bad, as you may have gathered from Visual Field Tests.

Please consult the history of eye drops, used with Dr. G
as per co-pays approved by you, for drops prescribed, the various drops and the variants used with different preservatives...the visits dates and documentation... conclusions of Dr. G
from your records. Please consult tests he and B did, etc. I was first diagnosed by G in April of 2008 (and I was confirmed legally blind, I believe in May or June 2008 by Dr B.)

In the interim, here is some contact infos here for Dr G:


Please be aware, that since oral Diamox tabs are now contraindicated for OS pressure management, dt low pressures in the right eye, the logic eads me to realize that time is now a variable that needs to be considered. Post op pressure in the left eye was 30 on Xalactan, very high despite the med, which suggests it's inadequacy, and suggests urgency surgical intervention.
Post Op pressure OD was 3mm/hg, immediately after surgery then it was 1 mm hg when checked the next day. Very low. This would suggest Diamox would run the recovering eye pressure way too low, if it were used to manage high pressure in the left eye now. Hence - Diamox for medical management at this stage is contraindicated.

Sincerely,

Gary Stone

The reasonableness of the letter led to an approval for the surgery. It was performed December 29th 2010. The letter suggests that perhaps all records were not reviewed, and that, perhaps. not all the information was gathered in one place when the rejection occured.

I don't think the Insurance company was trying to weasel out of paying. It is very good that they did pay, now they may pay for other patients who get rejections.
My doctor was going to do the surgery whether they paid or not, as, it was urgently

needed. But, it's appropriate for the hospital and the doctor to be reimbursed. I am very grateful the approval that came through, and grateful for the excellent performance of the surgeon. This particular surgery is somewhat experimental but it is not exotic.
Typically trabeculectomy is done in severe Glaucoma with severe

damage to the eye sight. The newer procedures may provided longer lasting results. There is a device that is planted into the eye that is like a tube, this gives a formed opening which prevents closure. This allows for the high internal pressures that do the damage in glaucoma, to come down.

Sometimes standard trabelectomy can "close up" in one year. The express shunt, aims
to prevent closure, and so far, it appears safe. The point of showing you this letter is to provide an example of how to present a grievance to an insurance company, and also to provide some information on newer procedures available to manage severe glaucoma, with significant vision loss.Here is a pdf file that describes the Trabeculectomy with Express Shunt.
http://www.escrs.org/PUBLICATIONS/EUROTIMES/07SEPT/EXPRESSSHUNTDELIVERS.PDF

I would like thank Blue Cross Blue Shield Insurance Company for reimbursing this surgery, and I hope they continue to reimburse this surgery for patients who need it, nationa wide. I would also like to thank the surgen who performed this surgery at Mass Eye and Ear in Boston. Hopefully  the insurers will be more open to the idea of this variation on the surgery because, it can lead to reduced repeat surgery caused by frequent  Trabeculectomy closure. The possibilty the insurer could, overall,  save money, should not be ruled out.