TKO

Our ordeal with the Insurance company has come to an end for now. Unfortunately we are the ones on the mat. TKO! We've lost our fight.

• Our appeal began with a request for a pharmacy exception as an effort to get our insurance company to cover some of the costs of an elemental formula. The formula costs $196 for a case of 6 cans of formula which Oliver consumes in about 15 days. Obviously, as he grows his nutritional needs will increase and he will consume the formula at a faster rate.
• July 26 -- Our drug request was denied because "EleCare Formula used to treat Eosinophilic Esophagitis are specific exclusions and are not covered benefit on this members plan."
• Sep 15 -- We appealed the adverse determination but the denial was upheld because "this is not a covered benefit per [our] benefit plan."
• Oct -- We requested an internal panel review hearing.

Today we had the Internal Panel Review Hearing. It was the last and final step in the appeal process. In preparation for the hearing we supplied the panel with copies of Oliver's medical records. Oliver's GI, PCP, Allergist, & Nutritionist wrote letters on Oliver's behalf explaining the importance of EleCare in his treatment as well as citing medical articles which indicate that elemental formula is the accepted medical practice for children with EoE. We also furnished complete copies of a dozen journal articles about EoE and its treatment. After all of this work the insurance company simply reminds us that "PHP determines whether a healthcare service or supply is a Covered Benefit. The fact that a Provider/Practitioner has prescribed, ordered, recommended, or approved a healthcare service or supply does not guarantee that it is a Covered Benefit even if it is not listed as an Exclusion."

The hearing went something like this:

• The participants were introduced
• We stated our case - i.e. that Oliver needs EleCare, it has been beneficial for him, and it is what all the doctors recommend
• The doctor for the plan stated their case - i.e. they don't cover Nutritional Supplements
• We were asked how much formula he consumed (currently 24-30 oz. per day) and what other foods he consumes
• We left and the panel deliberated

Based on our conversations it would appear that because EleCare is not Oliver's "sole source of nutrition" it is a supplement and therefore not covered. We contend that EleCare is Oliver's primary source of nutrition and the small amounts of fruits and beef that he eats are a supplement. He receives between 750 and 900 Calories a day from his formula, as well as a complete set of micro-nutrients, vitamins & minerals.

One of the big problems with the whole process is I still don't know what I needed to prove to the insurance to get them to cover his EleCare . . . perhaps there is nothing we could have done. It would appear that the appeal process is simply a formality to satisfy the requirements of the state, not something designed to help the consumer.

Where do we go from here? Now that we have a complete and utter denial of coverage from the Insurance provider we will look to other sources for help. The manufacturer has an assistance program, will we qualify? I'll let you know.