Lavon's case - What they said (Long!)

My case was decided by the Maximus Center for Health Dispute Resolution.
They are located in Rancho Cordova CA. I won't post the entire document,
which is six pages. If anyone wants to know more, i'm willing to scan the
thing and send it as an attachment to private emails. Please forgive me if
i take out my personal stuff. Btw, they got one issue about when my pain
began incorrectly....but, hey? It's on my side. Also, early in the stuff,
they incorrectly state the dosage of the med. It is correct in the rest of
it, and seems to be a typo.

"SUMMARY: The Center for Health Dispute Resolution, CHDR, has determined
that the requested medication is medically necessary for treatment of your
medical condition. Therefore, CHDR has decided that United Healthcare
Insurance Company's denial of the requested medication should be
overturned."

Gonna paraphrase a bit....the physician consultant is a board certified
neurologist who is actively practicing. They also state that the decision
cannot be appealed.

They purposefully did not include the neuro's name, but did give a short
bio;

"I am board certified in neurology, pain management and electrodiagnostic
medicine and I am actively practicing. I am a fellow of the American
Association of Electrodiagnostic Medicine and a member of the American
Academy of Neurology, the American Pain Society and the International Spinal
Injection Society. I am knowledgeable in the treatment of the enrollee's
medical condition, knowledgeable about the proposed treatment, and familiar
with the guidelines and protocols in the area of the treatment under review.
In addition, I hold a current certification by a recognized American Medical
specialty board in the area or areas appropriate to the treatment under
review. I have no history of disciplinary action or sanctions against my
license."

Then he states the records that have been submitted, like my medical
records, doctor's letter, lawyer's letter, and such. He takes about a half
page summary of my medical history and current situation, including that
i've been using Actiq since late '99.

After my summary, he states that "United Healthcare indicates the enrollee
does not meet the medical necessity criteria for the coverage of Actiq. At
issue in this case is whether the requested medication is medically
necessary for the treatment of the enrollee's medical condition.

"I have determined that the requested medication is medically necessary for
treatment of the patient's medical condition. Therefore, the Health Plan's
denial should be overturned."

He states some of the articles we submitted, as well as some he researched
himself. They include the following;

"Alturei, L., et al. Guidelines for the use of controlled substances in the
management of chronic pain. Pain Physician, 2003;6:233-257

Holmquist, G. The pharmacological management of chronic pain: The role of
opiods & adjuvants.

Landy SH, Headache, 2004;44(8):762-6 (ISSN; 0017-8748), PreMedline
Identifier 15330821

Tennant, F M.D, Dr. P.H., Pain patients threatened by health plan change in
medication benefits Intractable Pain News 2001; April

Reuters Health Oral Transmucosal Fentanyl Improves QOL in Patients with
Severe, Nonmalignant Pain

Simon, S MD, RPh Opiods and the Chronic Pain Management Paradigm: Time
for a Change? 2005;Nov. "

There is then a summary of my pain situation and the conflict with the
insurance....finally

ANALYSIS AND FINDINGS:

"Chronic pain has been recognized as the source for significant morbidity,
including loss of income, social isolation and low quality of life. A more
aggressive way to manage this condition has been stressed over the last two
decades including the use of powerful analgesics, including opiates. A
debate about the lasting analgesic effects over time versus the potential
side effects and complications, including tolerance, physical dependence,
addiction and even death has subsequently ensued. The medical literature
has suggested that in selected patients, long-term analgesia without
significant side effects and an increase in morbidity is possible. The
patient selection remains an issue of continuous debate. The America
Conference on Pain, which took place on New York City in June of 2007,
discussed this very issue. It was suggested that unless obvious
contraindications are present (such as active substance abuse issues), a
trail of systemic opiates may be the only way to assess the patient's
response to this group of drugs. It is essentially up to the prescribing
physician's discretion, to initiate and maintain such treatment. It would
also be his/her responsibility, to monitor the patient's response to it and
decide if long-term use of these drugs is clinically warranted."

(Lavon note...basically, insurances should keep their asses out of the
doctor's prescription pads)

"Notes from the patient's provider indicate "the patient's functional needs
depend on a regimen of Actiq and MS Contin (Lavon-states my dose) as well as
"no major opioid related side effects are present" and "the patient is
currently stable on current medication regimen but should problem arise,
medications will be adjusted as needed." Based upon this information and
the patient's clinical history, continuation of medical care including Actiq
(dose) oralets, four times a day, is medically necessary. Moreover,
removing this treatment from a patient that has been stable on this
modality of treatment for several years would clearly not be in the
patient's best interest. Therefore, I have determined that the requested
medication is medically necessary for treatment of the patient's medical
condition. The Health Plan's denial should be overturned."

Gotta admit it...i still am searching thru it for my mistake....that it
actually says i can't have them, and i'm just too stupid to realize it.

Deep peace,
Lavon



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Relevant Pages

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  • Re: Lavons case - What they said (Long!)
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  • Re: Lavons case - What they said (Long!)
    ... My case was decided by the Maximus Center for Health Dispute Resolution. ... Insurance Company's denial of the requested medication should be ... "I am board certified in neurology, pain management and electrodiagnostic ... I am knowledgeable in the treatment of the enrollee's ...
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