The New York State Appeals Process: Apparently Not Everyone Who The State Certifies To Prescribe Medication Is Considered ‘Educated Enough’ To Defend Their Patients’ Prescriptions During An Appeal

Government Red Tape & Legal Loopholes At Their Finest

After forty years of struggling with treatment-resistant depression, I finally found a clinic and team of doctors that have not only helped pinpoint genetic causes of my depression but that have also helped create a wonderful multi-pronged treatment plan that is actually helping me.

The person I see for the medication portion of my treatment plan was the one who first sent me for my Genesight test that discovered my genetic mutation.

(The full story explaining my genetic mutation and how it relates to my depression can be found HERE.)

He prescribed me a medication called Deplin, which provides my brain with a key substance my body is incapable of making on its own in any useful amount due to my aforementioned genetic mutation.  He started me on samples of Deplin right away and there was an immediate and extremely positive result.  For the first time in 40 years, I felt actual hope that I could have a life above and beyond my depression.

My insurance company, CDPHP, denied coverage of the prescription and my long battle began.  When I was called by the insurance company about the first denial and I explained my case further, it was suggested we re-apply for coverage, only to be met with yet another denial.

Meanwhile, I kept taking my samples, though the supply began to dwindle.

I spoke both with Assurex Labs who make the Genesight test that discovered my gene mutation, and PamLabs, which is the company that makes Deplin, about my ongoing battle for coverage and they both offered to help.  For my internal expedited appeal, I included not only approximately 50 pages of data showing the validity of genetic testing in the treatment of depression, but another approximately 50 pages specifically explaining my genetic mutation and the use of Deplin in its treatment.  Altogether, the paperwork I sent in alone, not even counting what my clinic sent in on my behalf, totaled well over a hundred pages.

Despite all the work put in by everyone involved, the internal appeal was denied.  Ironically, though CDPHP had over a hundred pages of paperwork faxed in, they rendered their opinion a few hours after the faxes were sent in, well short of the 72 hour time frame they had to review everything.  There was no possible way they could have reviewed everything before calling with their decision.  I’m honestly not sure they reviewed any of it at all.

I don’t believe it was ever a matter of the best interest of the patient with CDPHP.  From the beginning, their only concern has been saving money and avoiding adding another medication to their list of things they had to cover.  All explanations about how this medication was the only possible treatment available to me fell on deaf ears.

(My journey within the appeals process has been documented HERE.)

Meanwhile, my supply of samples of Deplin has been exhausted and I have found myself back where I once was, drowning in a sea of treatment-resistant depression that nothing seems to touch.

(The Explanation of the meds crash that followed can be found HERE.)

We began the process of filing for an external appeal with the state because, in New York state, even if an insurance company denies coverage, the state can overrule it if they see fit.  Unfortunately, as it has been explained to me by my treatment staff, appeals don’t always go well because insurance companies and the section of the government that oversees their decisions usually work in tandem, proverbially washing each other’s backs.

I began correspondence with a local newscaster, as well, who was well-known for her health advocacy work.  She advised me that, in her experience, external appeals tend to go 50/50 and to please let her know how it turns out because she was interested in the story.

Meanwhile, the gentleman in my treatment team who was in charge of my medication prescriptions began the lengthy process of formatting a detailed external appeal for the state, explaining once again that there is no alternative medication for my condition and including multiple articles from approved medical journals based on their guidelines that support his diagnosis and prescription of Deplin.  He sent in his portion of the 72 hour expedited external appeal last Thursday, 3/16/2017.

I heard back from a reviewer from the consumer assistance unit of New York State Department of Financial Services today, Tuesday, 3/21/2017, that they have not yet assigned an examiner and cannot do so until they receive an attestation from a doctor, specifically someone with an MD or DO after their name.

The gentleman who has been doing my medication management for two-thirds of a year now is licensed to prescribe medication in New York State.  He has a multitude of letters after his name, including CAQ & PA-C, however, though New York State AUTHORIZES him to prescribe to patients, he apparently is not allowed to assist in their medication appeals because he does not have an MD or DO after his name.

As explained by the reviewer, “The law says the attestation has to be completed by a physician.  The education law defines a physician and an MD or DO.  So in order for this to go external you will need to have the attestation completed by a physician.”  This means that, though New York State allows people with other degrees to PRESCRIBE medication, their appeals department uses a specifically restrictive and exclusionary definition as a legal loophole to mark as invalid and discard any appeals sent in by the treating physician unless they have one of two specific abbreviations after their name.

It does not matter that, according to the Merriam-Webster dictionary, physician is defined as “a person skilled in the art of healing; specifically :  one educated, clinically experienced, and licensed to practice medicine as usually distinguished from surgery”.  Speaking from a legal perspective, the Law Dictionary defines a physician as “A practitioner of medicine; a person duly authorized or licensed to treat diseases; one lawfully engaged in the practice of medicine, without reference to any particular school.”  Speaking from a medical perspective with regards to the term physician, the Medical Dictionary states “In the UK it refers to a specialist in internal or general medicine. In the USA it is a more general term for a medical doctor.”  Despite the seemingly broader and unified consensus of this definition, New York State has its own much smaller and less inclusive definition of physician which they apparently use to disregard and nullify otherwise valid patient appeals.

My mind is beyond blown at the loopholes this department is using to prolong this appeal.  In my disgust, I went so far as to ask them if I am supposed to see yet another doctor beyond my treatment team and to please explain to me how the state can certify someone to treat patients and prescribe medications one moment and then in their next breath deem them unqualified to speak on a patient’s behalf as to why they need that prescription.  It’s irrational to the point of being ludicrous.

Thankfully, when I spoke to both the director of the clinic where I am in treatment and the gentleman in charge of my medication management and they both assured me there was a supervising psychiatrist who would be in the office tomorrow who can assist me further.  This supervising psychiatrist apparently has the correct letters after his name to re-submit paperwork on my behalf.

I am beside myself with disbelief at this whole fiasco.  None of this should be THIS hard.  It’s a matter of simple facts.

FACT: I have a gene mutation that renders my liver incapable of breaking down a nutrient my brain needs in order to treat my depression.  Without this broken down nutrient, the neurotransmitters in my brain cannot function properly.

FACT: There is a synthetic version of this nutrient on the market called Deplin.  I have tried it for months and it works for me.

FACT: There is no other alternative on the market and no other possible treatment that could give my brain what it needs.  This is the ONLY treatment available for my genetic mutation and the ONLY way that any other antidepressants or anti-anxiety medications prescribed would work for me in the treatment of my depression.

Those three facts alone should be enough reason to approve this medication for me.  Yet the insurance company has denied it multiple times and now the state is dragging its heels, refusing to even assign an examiner until someone with the correct letters after their name signs and submits the same forms that have already been submitted.

You would honestly think that anyone who can prescribe medications in this state could defend their prescriptions in the appeals process on behalf of their patients.  It makes perfect sense.

Except to New York State.

It is complete insanity.  The people making health coverage decisions need to start considering the lives and the health of the people involved instead of worrying about saving a few dollars here and there.  They need to start considering doing what is in the best interest of the patient and not worry about “winning” or “proving points”.  This is NOT a game.  I’m fighting for my life and my mental health here.  I’m fighting for the ability to get the treatment I desperately need so that I can get better.

My heart goes out to everyone out there fighting the appeals process, trying to get their treatment or medication covered.  It should NOT be like this.  Doctors, therapists and insurance companies should be working hand in hand to do what is best for the patient, not denying coverage just to save a buck.  I am blessed to have an amazing treatment team that has been standing behind me every step of the way and assisting wherever they can, yet most days, I am still overwhelmed and frustrated beyond belief trying to deal with this lunacy.  My appeals process has been ongoing for over half a year now and it is becoming harder and harder each day to keep fighting and not just roll up in a ball and cry.  Some days, there is no fight left, only tears.  I cannot imagine having to deal with something like this on my own yet unfortunately many people do.  My heart sincerely goes out to each of you.  Stay strong, keep fighting and please don’t lose hope.

 

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One thought on “The New York State Appeals Process: Apparently Not Everyone Who The State Certifies To Prescribe Medication Is Considered ‘Educated Enough’ To Defend Their Patients’ Prescriptions During An Appeal

  1. Pingback: Victory is Mine! Fighting for & Winning Coverage is Possible! | Unlovable

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