Many times our insurance companies refuse to pay for things that our doctors order and we really need. When I worked in home care, part of my job was to get insurance authorization for home care nursing for children who require in home nursing. So, I have an advantage in fighting for my own care. I'm hoping that I can share my experience with you. The above link is someone else's information as I figured that the more information that you have the better.
For those of us with RSD, the main thing that we try to get approved is Ketamine. Here is my suggestion on how to get pre-authorization for Ketamine Therapy. It is easier to get preauthorization than to have the treatment and have the insurance company deny your claim as you may be stuck paying for the treatment while you fight with the insurance company!!!
You need to get Ketamine preauthorized. Most insurance companies are still saying that the treatment is experimental after 10 years. If you want your insurance company to cover Ketamine Infusions and they are telling you that they are either “experimental”, “educational” or “investigational”; here’s what you need to do.
1) You need to establish that you have CRPS/RSD by getting your RSD doctor to write a strong letter stating that you have severe RSD that will only respond to Ketamine.
2) You need to write a BRIEF history of your RSD experience. For example:
· March of 1996 Franc Liss Fracture of right foot resulting in burning pain treated by casting and PT
· March of 1997 After a year of continued extreme pain, a fusion was done of right foot
· December of 1997, I was referred to an outpatient Chronic Pain Program at Bryn Mawr Rehabilitation Hospital when burning pain, purplish discoloration and swelling remained in the right foot. This program was run by a physiatrist and included PT, OT, individual psychology, group therapy and biofeedback. The Physiatrist ordered a three phase bone scan which showed that I most likely had RSD. He started me on Neurontin and referred me to Hahnemann’s Neurology Clinic.
· April 1998, I saw Dr. Alyssa LeBell who did a Laser Dobler Study and Bier Block. She confirmed the diagnosis of RSD.
· 1998 – 1999; multiple blocks including lumbar sympathetic, and thoracic. Pain spread up the right side and to the left side. Hospitalized for continuous epidurals, Lidocaine drips and finally for a trial of a medication pump.
· February 1999; Metronic Medication Pump was placed. Increasing amounts of medication were needed to get any relief.
· 2001; Dr. LeBell left the practice and care transferred to Dr. Robert Schwartzman who suggested Ketamine Coma Treatment in Germany in October.
· Feb 2002 – 2009 Ketamine out patient Ketamine infusions and inpatient awake infusions maintained my pain at a tolerable level.
(notice that I didn’t go into the fact that I had my gallbladder out, had cancer, had back surgery, etc because it isn’t relevant to my case for Ketamine)
3) You need to show them that Ketamine is no longer considered experimental. I have put together this set of paragraphs showing scientific studies that Ketamine is now considered Level I treatment for CRPS. Thanks to Barb, who had PA Dept of Health review her daughter Stacey’s case, I have the wording that got her insurance to reverse their denial. I have removed Stacey’s information and made it generalized for you to use in your own battles. Here it is.
There is nothing in the language of the health plan’s Definition of Medical Necessity that would prevent the enrollee from continuing to look for further treatment options for refractory CRPS. IV Ketamine treatment is medically appropriate for the enrollee’s condition; given to improve physiological function; consistent with the current medical literature; consistent with the diagnosis of the condition; is not given for convenience; and not considered experimental for this enrollee per the current standards of care in the medical community.
In regard to the Ketamine infusion, the health plan considered it to be in the Experimental or Investigational realm of treatment options for refractory CRPS. Based on the discussion below, and the fact that anesthetic dose IV Ketamine is now supported by LEVEL I data in the literature, the enrollee feels that the enrollee does meet the criteria to receive this form of treatment.
The health plan deemed the use of IV Ketamine to be not “Medically Necessary”, but also stated that it was against the health plan’s policy because it was considered “Experimental or Investigational”. This is not an accurate statement and goes against the available medical literature. There are now two publications in the peer-reviewed literature that have LEVEL I date, derived from Phase III randomized, placebo-controlled clinical trials supporting the use of anesthetic level IV Ketamine in patients with refractory CRPS Type 1 (6,7) In the study by Sigtermans et al, they studied sixty (60) patients and noted a statistically significant improvement in pain control (p<0.001) in the group of patients and noted a statistically significant improvement in pain control (p<0.001) in the group of patients receiving IV Ketamine in comparison to the group that received the placebo infusion. The study by Schwartzman et al was designed very similarly and also noted a statistically significant improvement in pain control (p<0.05) in the group receiving IV Ketamine. In an older paper by DR ME Goldberg you could support the position that IV Ketamine was experimental/investigational (9) However, Dr Goldberg’s position is further clarified in a more recent publication (10) In this paper, he does not state that IV Ketamine is not efficacious or appropriate for patients with severe or refractory CRS, nor does he state that it should be considered only an experimental or investigational treatment modality. What he does say is that there is selectivity in the responsiveness of various patients with CRPS to IV Ketamine and that this aspect of its use is still unclear and will require further study. Therefore, impatient admission for the admission of IV Ketamine is considered the standard of care in this enrollee’s case.
References:
1. Brehl S. An update on the pathophysiology of complex regional pain syndrome. Anesthesiol 2010;113:713-725.
2. Albazaz R, Wong YT, Homer-Vanniasinkam S. Complex regional pain syndrome; a review. Ann Vasc Surg 2008;22:425-429.
3. Rowbotham MC. Pharmacologic management of complex regional pain syndrome. Clin J Pain 2006:22:425-429.
4. Ben-Ari A, Lewis MC, Davidson E. Chronic administration of Ketamine for analgesia. J Pan Palliat Care Pharmocother 2007;21:7-14.
5. Correll GE, Maleki J, Gracely EJ et al. Subanesthetic Ketamine infusion therapy; a retrospective analysis of a novel therapeutic approach to CRPS. Pain Med 2004:5:263-275.
6. Sigtermans MJ, van Hilten JJ, Bauer MC, et al. Ketamine produces effective and long-term pain relief in patients with complex regional pain syndrome type 1. Pain 2009;145:304-311.
7. Schwartzman RJ, Alexander GM, Grothusen JR, et al. Outpatient intravenous Ketamine for the treatment of complex regional pain syndrome; a double-blind placebo controlled study. Pain 209;147:107-115.
8. Jeon U, Huh BK. Spinal cord stimulation for chronic pain. Ann Acad Med Singapore 2009;38:998-1003.
9. Goldberg ME, Schwartzman RJ, Torjman MC et al. Ketamine infusion successful in some patients. Pain Physician 2010; 13:E371-372.
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