My letter of appeal
As I’ve mentioned in the past, my insurance company will not cover the search for a bone marrow donor.
On Oct.13 they sent an official letter of denial, describing the “search and cell acquisition as a non-covered incidental.”
I’ve responded with a letter of appeal. My expectation is they will issue a more formal denial from the Medical Management Appeals Unit, but I am very intrigued as to what criteria they use to deem a bone marrow donor search as a “incidental.” Now, I know I’m anything but an objective, unbiased observer, but it seems like acquiring healthy marrow is sort of important in the transplant process.
Oh, If you do decide to read my appeals letter below refrain from e-mailing me with any grammatical or spelling errors you’ve spotted. The letter has been mailed and all it will do is anger me. I can see it now, my letter being e-mailed around Blue Cross Blue Shield headquarters, insurance workers in their tiny cubicles attempting to fight off fits of hysterical laughter brought on by my horrendous usage of your, or misspelling of marrow.
To Whom it May Concern:
This letter is in response to your letter of October 13, 2009.
The correspondence stated a bone marrow donor search and cell acquisition “will be denied as a non-covered incidental.” I formally appeal this decision. Three and a half months ago I was diagnosed with severe aplastic anemia—complete bone marrow failure. My hematologist has advised there needs to be a formalized donor search, funding of the bone marrow donor search is a necessary component to my treatment plan.
If internal denial is upheld, upon response to this correspondence please furnish detailed instructions for initiating external appeals of the denial, including but not limited too, time limits and the name and contact information of the individual at Empire Blue Cross Blue Shield Empire.
Please provide the following:
- Statement of specific medical reason for denial—why Empire Blue Cross Blue Shield believes the search for bone marrow is not essential in my treatment plan. Please include the company provision that excludes a donor search.
- The name, medical license number, and title of the person or persons making the denial decision.
- What options you will fund to assist me in finding a bone marrow donor match.
I ask that you please expedite this process, as I am currently transfusion dependent, receiving 10 to 12 units of packed red blood cells & or platelets a month. Bone marrow transplant is the only cure for severe aplastic anemia.
Sincerely,
Matthew C. Sheehan
November 1st, 2009 at 4:04 pm
Matt Sheehan,
Oh my GOD. I have no idea what made me think of you BUT I had a dream and I was freaked out and started asking people I knew who knew you if you were ok and if something bad happened to you..Martin P. told me he had seen something about you in the paper a few months back so I just googled you and found the article and then found your site. I am so proud of how far you’ve come, you have become such a inspiring young man. I am blown away at your illness and am so sorry for all the pain and stress you are going threw and that you have to put your life on hold and fight for what should be the least of your worries INSURANCE company B.S. it is so sickening. I dont know if your brother Jon was a match or not, but If not I just read your letter and was wondering something, if people volunteered privately can they get tested and will the insurance cover to have them tested or something atleast? I want you to know I want to help you in and way I possibly can. If I can get tested for you I will do that and also if Im not a match I can get together a bunch of people to also get tested for you…jesus Matt I am so sorry this was all sprung on you at this poijnt in your life when you are just getting out there and getting your life started. Im not sure if you will get this message or not so I am going to try to copy n mail it to any other link you have on here. To get back to me you can either email me at tiffanypineau@yahoo.com, or u can find me on myspace.com/tiffanypineau or im also on facebook just type in my name on the search ok. my cell number is 973 570 0025 call me anytime. Please let me know anything ast all I can help you with cause I read that you’re at ur parents in Green right now and I am at home in Green a few houses away ok so I swear if I dont hear from you I will come knock on your door! If you need annnnything during the day I am home all day with my 2yr old son and I would come help you with anything at all, if you need a ride or need someone to cook for you or even just to keep you company I got your back! Pleeeease let me know that you’re ok and wb soon or call or whatever u want. I pray that you are going to be ok, I know you will be but im praying for you. Hang in there, ur amazing.
Sincerley,
Tiffany Pineau
November 2nd, 2009 at 2:37 pm
Hey Matt–
I’ve been reading your last few posts and I can’t believe the trial you’ve had to endure. It’s ridiculous that your insurer denied coverage for this search, but I think making a formal appeal was definitely a smart move.
I talked with a representative of the National Bone Marrow Registry (sponsors of the “Be the Match” program) and he said that many people are denied coverage for the search, but that when they appeal the insurer usually reviews and changes their decision. I truly hope that’s the case for you!
He also mentioned that finding any precedent of your insurer covering a similar search would be helpful, but I don’t know exactly how to find that. I’m going to do a quick search through the Westlaw database and see if there are any legal precedents. I’ll let you know if I think of anything else!
December 14th, 2009 at 2:21 pm
[...] to my insurance company after they denied coverage for a bone marrow donor search(read the appeal here). After receiving nothing back for weeks, I took the advice of a friend’s father and resent [...]
January 14th, 2010 at 10:27 pm
[...] Blue Shield’s denial of coverage for donor search Jan.14, 2010 in Personal, healthcare In October I posted my letter of appeal after Blue Cross Blue Shield’s told me it would not cover my bone marrow donor search. After [...]