I'm suddenly reminded of the DMV scene in Zootopia, except I think insurance companies do it on purpose.
Today I had a minor and unexpected victory, and I think I might know why it worked, so I thought I'd share it.
Unfortunately, I have to mask any clinical information, so you'll have to take my word on a number of points. Some things may sound peculiar or not-thought-out, but like most cross-sectional views of a patient's medication regimen, if you knew the full history, it would make sense.
Here's what happened. I needed to get a PA for a new medication, M. The patient had had trials of multiple
A number of months ago, I had tried to get a PA for a new med for this patient, and the application was rejected, despite the fact that the criteria were obviously met. I didn't have the energy to pursue it then, and there were one or two more covered meds left to try.
The difference now seems to be that I've since had a Genesight test done on this patient. As I've described in the past, I have my doubts about the whole genetic testing business, but I used the test results as documentation to support my rationale. M was in the "Green Column", and the other meds in that column had already been tried.
It worked! Who knew? I'm only guessing that that's the reason, but I can't think of any other difference. Same patient, same insurance company.
It wasn't a pure victory, though. This medication has a starter pack that's used to titrate gently. THAT wasn't approved. And using a single dose form, starting lower, and then increasing the number of pills per day, well, that wasn't covered, either, because it involved too many pills. What I needed to do was skip the recommended titration, and go straight to the next dose up. Not dangerous, but possibly hard to tolerate.
To me, it feels like a punishment for asking the insurance company to cover the medication.
I guess with insurance companies, you take what you can get.