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    APPEAL DENIED!!

    We applied for Gilenya approximately 45 days ago and was denied by BC/BS of LA. My Neuro's staff put together an appeal package and submitted it two weeks ago. When I saw my Neuro last Monday I talked to the nurse that was handling the appeal and she told me she had spoke to BC/BS and they reviewing my file.

    I called today to let my Neuro know I was having extreme difficulty walking due to legs weakness and spasticity. I was talking to the nurse and before she transferred me to my Neuro she told me the appeal had been denied. She had not even had time to tell my Neuro.

    Well when I was talking with my Neuro and telling him my problems he said we just need to wait to see if Gilenya gets approved. That's when I told him it had been denied. I told him he needs to call BC/BS himself if we are going to have shot at getting this pushed through. He assured me he would call them immediately and let me know as soon as he heard something.

    The bottom line here is Gilenya is my last shot at a DMD. I have tried everything else and nothing worked. I'm JC+ so Tysabri is out. And the worst part is I am progressing at a steady and rapid rate. What's a person supposed to do?
    Dx'd 4/1/11. First symptoms in 2001. Avonex 4/11, Copaxone 5/12, Tecfidera 4/13 Gilenya 4/14-10/14 Currently on no DMT's, Started Aubagio 9/21/15. Back on Avonex 10/15

    It's hard to beat a person that never gives up.
    Babe Ruth

    #2
    If you have not been on Tysabri, even tho you are jcv+ you could still go on Ty for a year-there has been only 1 case of pml (pretty sure) of someone being on Ty for under 13 months. It's a thought

    Anthem was on 60 Minutes last night for being an insurance company that doesn't seem to care about it's insured I think they are part of BC/BS.

    Good luck
    Linda

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      #3
      As many meds as you've tried, that is ridiculous. There is no reason for them to deny you again. I have BCBS as well from a different state and I'm fighting the same battle right now. It's so frustrating when your dr prescribes a medication for a reason, but then your insurance has to fight back and refuse, yet they'll put their stupid little statement on the bottom of the denial letter that they're not stopping you from taking it, they just won't pay. It sounds like they're stopping you from taking it to me
      Diagnosed 1/4/13
      Avonex 1/25/13-11/14, Gilenya 1/22/15

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        #4
        I'm wondering if the physicians that work for the a Insurance Company are saying I've progressed to SPMS and there would be no need for me to take a DMD? That though just occurred to me.

        My Neuro and I had that very conversation last Monday, that I have progressed to SPMS. He said he though I was have "One continuous long flare." IMO that's the same thing as SPMS just worded a different way.

        So if we're thinking that the Insurance Company physicians could be thinking the same thing. Hence the two denials. I'll just have to wait and see what happens after my Neuro talks to them. I'm praying it works. Right now life is ****!!
        Dx'd 4/1/11. First symptoms in 2001. Avonex 4/11, Copaxone 5/12, Tecfidera 4/13 Gilenya 4/14-10/14 Currently on no DMT's, Started Aubagio 9/21/15. Back on Avonex 10/15

        It's hard to beat a person that never gives up.
        Babe Ruth

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          #5
          What was their reasoning for denying you? The reason I ask is because I'm going through the same thing right now, but my neuro told me today that if my appeal isn't successful, that BCBS is changing their criteria January 1 to where you only have to try one med unsuccessfully before they'll approve you for one that's not in their preferred list. Of course, as many meds as you've tried, failing on them shouldn't be an issue with a denial for you, so maybe it's different.
          Diagnosed 1/4/13
          Avonex 1/25/13-11/14, Gilenya 1/22/15

          Comment


            #6
            Tysabri is not contraindicated automatically because of a positive test for the JC virus. There is more understanding of the risk levels now, based on a range of results. As was explained to me, they base it not on positivity or negativity, but on LEVEL of JC virus detected. Test results showing level of .04 are considered positive. My level was 2.5; My neuro's secretary called that high positive. I am no longer a candidate for Tysabri at that range. You still may be if your levels are low enough.

            Also, if you are not a candidate for Tysabri, you might be a candidate for Lemtrada. I am on the short list for it after my neuro advised me the MRI and symptoms showed that Gilenya is not effective for me. He is taking me off Gilenya after I finish this month's dose pack, and initiating the process for me to go on Lemtrada.

            Being forced to wait 180 to appeal again after a denial is poppycock. It's an administrative "rule" that your insurance cooked up to make you give up. Don't give up. There are parameters they have to follow when basing their decisions on denials, and if you can find out what those parameters are you can poke holes in their case when you appeal. Read your contract. Seriously, read it. Now go kick some butt.

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              #7
              I wish I had seen that 60 Minutes though it probably would have just made me more irate than I am. My Gilenya request was denied and now, STILL, waiting on my neuro's office to work on the appeal which has been going on for several weeks. Gilenya says they have received nothing from the neuro.
              A big part of my anger is that now we are in a new insurance year. Trying to get Aubagio last year screwed me over charging my insurance a huge amount for the drug putting me in the doughnut hole so none of my other medications were covered from Oct. until the end of the 2014. NOW Gilenya is going to mess me up in the very beginning of the year until the end. I was hoping Gilenya would have gotten in on last year's screw up. I can't take this.

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