denied again! Wheee!

[sfmcfar]

Well, the saga continues. My appeal was denied by MAMSI, again using the "experimental" label. I haven't seen their formal response yet, but I received a "courtesy" call from their appeal "auditor" informing me of the decision. Here's an entertaining recap of the conversation:

Me: "Did you personally see my appeal?"
She: "Yes. My job is to ensure that MAMSI meets the guidelines for federal employees in their appeal process."
Me: "If that's your job, then please explain to me why MAMSI is choosing to violate the Federal Employee Health Benefits Plan regulations by labeling FDA-approved procedures as experimental, which was the basis for my appeal."
She: "I can't answer that. I'm not a medical person."
Me: "I'm not asking you a medical question. If you *really* did read my appeal, you would have read the regulation, which was included in the appeal. I'm simply asking you why MAMSI believes they don't have to comply with the regulations."
She: "You don't understand. I have no medical training."
Me: Sigh......

So, the next step is to appeal to the US Office of Personnel Management, which has given every indication that they'll reverse the decision if sufficient evidence is shown that I meet the FDA indications for use.

Fortunately, my back is in a fairly "quiet" period so I can probably wait the 60 days for OPM to respond to the appeal.

Onward...

[Harrison]

Sorry Stan.

Keep up the fight!

[amanda]

Hi Stan, I'm in the same boat. Same song, different insurance. I thought the doctor's decision ruled. I guess "Non-Medical" insurance company employees know better than the doctors. What can OPM do?

[bclervi]

Thanks to all of you for responding to me today about the insurance question. At least I don't feel like I am out fighting on my own now.
Becky

[Rein]

Stan

Do you think you could get a copy of those "guidelines"?

It's very possible the person who called you up was only reviewing your appeals process for things like number of days from the time the appeal was submitted until it was answered, which would certainly explain why that person had no medical training and needed none.

[sfmcfar]

Rein,

You may be right. She was definitely not hitting on all cylinders. The thing that *really* gets me is that MAMSI isn't playing by the rules. Most insurance carriers can decide for themselves what's "experimental" which is why so many people on this board are getting screwed. The exception is that if you're covered under a Federal Employee Health Plan (as I am), the carrier is not allowed to label anything that's FDA approved as "experimental." And when I try to point this out to MAMSI, they act like they don't even hear me. I'm reminded of the "Far Side" cartoon called "What dogs hear" - I think that MAMSI hears "blah blah blah blah artificial disc blah blah blah".

My hope is that my appeal to the US OPM will resault in MAMSI having to pay a fine for violating the regulations.