As most of you know, I have a Don Quixote Complex - I like to fight battles against The Man, the more hopeless the better. Most of the time, they are the pro bono work I do with Larra on helping people get approved for the DS, but lately, I've had other stuff on my plate.
- My ongoing fight with Aetna to cover my daughter's oocyte cryopreservation, which they insist is a contractual exclusion. However, in her case, we are arguing it is not for deferring pregnancy - it is to preserve her fertility because her endometriosis is destroying it, and it falls under the category of medically necessary as stated by the American Society of Reproductive Medicine.
- We have already self-paid for one round, but she needs at least one and probably two more, and they cost thousands of bucks per round.
- I am trying to get Aetna to see this as the equivalent of breast reconstruction after mastectomy - it may be essentially the same procedure as the elective procedure, but the medical necessity makes it different.
- We have been screwed around at every step of the way - this has been going on for nearly a year.
- They gave us a final denial in June, and THEN denied that she was entitled to External Medical Review because it is a contractual exclusion.
- However, I just discovered (in working on someone else's case, below) that they MIGHT have to give us a medical review after all. I submitted a 2 lb appeal package on Monday. (What particularly irks me about this case is that her plan is self-funded, which means it's no skin off Aetna's nose, because they won't pay the claim. But of course they are protecting their own asses.)
- I'm probably going to lose.
- My ongoing fight with my own dental insurance company, which refused to pay for crowns on teeth that had cavities, cracks and chunks of tooth chipped off (my lower middle six incisors).
- I already had the work done, but I am still fighting for coverage.
- DeltaDental LIED about the condition of my teeth, and called my dentist a liar, and it completely cheeses me off, even if it's "only" $1500.
- I just filed papers in rebuttal of the VA insurance agency's upholding of the denial by asking for their LIE to be be reviewed.
- I'm probably going to lose.
- My battle to get Charles' diastasis plication covered - WHICH I WON!!
- My fight to get my brothers on Medi-Cal (and Cal Fresh food aid) - WHICH I WON!!
- My fight to get my very ill younger brother to see the out-of-county specialist - WHICH I WON (although it turned out he didn't have what it seemed he did).
- My fight to then get him to stay on straight Medi-Cal so he could continue to see specialists - WHICH I WON!
- My fight to get him to see a new in-county specialist without going through a ridiculous referral process - WHICH I WON!
- I tracked down the specialist's email address through his publications on PubMed and wrote to him directly, explained my brother's plight and asked him if he was up to the challenge - and he agreed to take my brother on as a patient and circumvented the referral process.
- My brother saw him on Monday, and they are trying a different approach, which i don't believe will work, but at least it's thinking outside the "You have severe IBS - live with it" approach - thinking it might be myofacial pain, and treating with gabapentin. We'll see how that goes.
- My brothers also have had a very difficult situation with the CA EDD (employment tax people) stemming from a defunct business partnership between them and a (former) friend they had been in business with in the early 1990s, which ended in a very bitter dispute. A few months ago, after hearing nothing about this for 20+ years, the EDD suddenly started garnishing all of the money out of the account they use for their current business (and - another story - that they use for their personal expenses too) based on tax liens my brothers knew nothing about (the partner was supposed to have been paying them and stole the money).
- When I took over their financial situation in June, I got the EDD to put a stay on the garnishments (and even to refund the last one which was over $1000), but the stay is temporary.
- In the meantime I ordered copies of the records of these tax liens, so I could study the validity of the claim, and to determine how much money was being taken from their former partner. So far, four months later, I have received NOTHING from EDD.
- But in the meantime, I ordered copies of the liens, and discovered
- (1) one of them didn't exist in the LA County Recorder's office and in any case expired in 2001;
- (2) two of the liens expired in 2003; and
- (3) the other four liens comprised two liens and two 10 year extensions of those liens to 2003 - which were also expired.
- In other words, the EDD has apparently been illegally enforcing expired liens against my brothers!
- I sent a fax to the EDD on Monday, asking for telephonic acknowledgement - and nobody responded. So today, I called again and got some BS about how they don't accept faxes anymore (??) and I needed to print out the fax and snail mail it to the EDD.
- I sputtered and hissed, but I did that today.
- If I win their money back, it will be applied to a DIFFERENT problem they also have.
- I just want these enforcement actions to go away - and to make the EDD admit they were acting illegally. In fact, my brothers' situation was such that the EDD was even in the wrong for extending the liens in 2003, so I'm going to make them clear their credit records of these over 10 year old extinguished debts.
- My former SIL came over yesterday and explained a plight he was in - mostly self-inflicted, but he was being treated unfairly because of a political situation with the local professional soccer team, and was being unfairly and falsely accused of something that didn't really happen, and was suspended from attending any matches - so I drafted a strong letter for him, which was then reviewed (and made even more strongly worded, if you can imagine!) by a "real" lawyer friend of his - and we'll see if the ban gets lifted.
- It was also his fault - he got drunk at an away game and was escorted from the stands - but he was not arrested as was being asserted, and there was no "investigation" ongoing which he was told he would have to wait until it was concluded before they would decided whether to lift the suspension.
- No investigation = no valid suspension.)
- He will owe me another big favor if this works.
- And today, I won a REALLY big one (with the help of Larra and others of course). We had a patient with a special medical situation who was being denied access to a specialty hospital for the DS surgery - and several of the patient's treating physicians insisted that this surgery MUST take place at the specialty hospital - but the self-funded plan had a contractual limitation to having bariatric surgery at a bariatric "CME" (which we all know is BS).
- The patient had been denied by the insurance company for the contractual exclusion, and then the self-funded employer upheld the denial, lamely offering hospitals without these special facilities, or a non-DS doctor.
- Their decision did NOT address the several letters from the physicians, and I went ballistic on them.
- Again, they would NOT let me speak to the guy who wrote the decision - so I Google-Fu'ed him, and found his directly line, and left a lengthy and colorful voice mail message on Friday, along with sending a detailed 19 page fax.
- He called me back on Monday, yesterday, and then again today - each time, the conversations went on for over 30 min.
- And today, he called to say that he used my arguments to go back to the appeals panel that had decided against the patient, and they granted the patient the waiver to have surgery at the specialty hospital! WE WON!!
