It appears you have not yet Signed Up with our community. To Sign Up for free, please click here....



Cystic Fibrosis Message Board
Post New Thread   Closed Thread
LinkBack Thread Tools
Old 02-02-2005, 10:06 AM   #1
Newbie
(female)
 
Join Date: Feb 2005
Posts: 3
kerrig HB User
Question PGD and insurance coverage- help!

My husband and I found out that we are both carriers for CF when I was pregnant with my son. We had our son tested for CF at 11 weeks old and thankfully he does not have the disease. We want to have another child but now that we know we are both carriers we are considering PGD (prenatal genetic diagnosis) in order to reduce the chances of having a child with CF. We were told that we had to write a letter to our insurance company requesting they cover the procedure. Has anybody had any experience with this? Did you manage to get insurance coverage and if so do you have any advice for us? We would not be able to afford the procedure without coverage since it costs about $23,000. Any advice would really be appreciated! Thanks!

 
Old 02-02-2005, 01:17 PM   #2
Senior Veteran
(female)
 
Join Date: Nov 2003
Location: Midwest
Posts: 2,006
Ratatosk HB UserRatatosk HB User
Re: PGD and insurance coverage- help!

I believe Sherry092 posted on this last year. Was able to get coverage from her insurance company....?

 
Sponsors Lightbulb
   
Old 02-02-2005, 04:28 PM   #3
Newbie
(female)
 
Join Date: Feb 2005
Posts: 3
kerrig HB User
Re: PGD and insurance coverage- help!

Thanks so much!!!! I did read her post but she had no responses so I'm not sure how it worked out for her. Hopefully she was able to get the coverage. I was hoping somebody else might have some more info for me, especially advice on how to convince the insurance company to provide coverage.

 
Old 02-02-2005, 06:54 PM   #4
Member
(female)
 
Join Date: Feb 2004
Posts: 92
sherry092 HB User
Re: PGD and insurance coverage- help!

Kerrig,

You must have missed some of my replies- my post started with my PGD approval, the process, my embryo report... I'd go back & check it again if I were you.

We were able to get PGD covered through our insurance company by writing a very detailed, heartfelt letter. Not many people have been able to get this covered by insurance so I am glad you're on Healthboards- I doubt you'd find many other success stories out there. They covered almost 100% and we didn't even have IVF coverage on this plan. Here's some letter writing tips that made our letter a successful one:

1. I explained our situation, the odds of it happening again, briefly what CF is and detailed our medical bills for my son's first year of life (with photo copies).
I then went on to explain that we had no intention of raising our son as an only child, but wanted to expand our family in the safest way possible (I would use this almost word for word because I found out that insurance companies cannot prohibit you from expanding your family).
Then explain PGD (cut and paste from a website) and how it reduces the risk to almost nil. Be upfront about the cost and remind them of present and future needs of people with CF-- perscriptions, hospital stays, the vest, transplants, etc. While initially PGD is expensive, over time it is far less expensive than the cost of care for a person with CF. This was my basic outline for the letter.

2. Tell them there are no procedure codes for PGD and that this cannot go through the normal approval process.

3. Make sure you call and find out how to send this to their first level review team, if this gets sent via regular channels, it will probably be discarded. Noone knows what PGD is and any random clerk will not know what to do with this info.

4. Appeal to the emotions of the person reading your letter- the fact that you are trying to prevent this disease from happening to another human being, that knowing this process is available, but not being able to afford it is completely unfair to your unborn child.

5. Noone but you can write this letter-- my IVF clinic has been unsuccessful 100% of the time- they do not want to hear from doctors or office workers, they need to hear from their client, the one paying the premiums.

Sorry this is so lengthy, but clearly I am very passionate about this. I was lucky enough to get pregnant my first round of PGD/IVF and am due in approx 3 weeks

Good luck...

Last edited by sherry092; 02-02-2005 at 07:09 PM.

 
Old 02-03-2005, 05:39 AM   #5
Newbie
(female)
 
Join Date: Feb 2005
Posts: 3
kerrig HB User
Re: PGD and insurance coverage- help!

Sherry,
Thank you so much for all the great advice!!!! That is exactly what I needed to hear. We are hoping that we can convince our insurance company to cover PGD. I have been doing research both on CF and PGD so that I can include as many detailed facts as possible in the letter to help make our case. I will definitely go back and find your previous posts. Congratulations on your new little bundle of joy!!!!!!! If you think of anything else that might help our case please let me know. Thanks again!
Kerri

 
Old 08-10-2005, 08:50 AM   #6
Newbie
(female)
 
Join Date: Aug 2005
Posts: 1
blvinmircls HB User
Re: PGD and insurance coverage- help!

I am so happy to find women talking about CF and IVF. I, like kerrig found out during pregnancy that my husband and I were carriers on the DeltaF508. No family history, but my father who passed away before we found out was extremely active in the Cystic Fibrosis Foundation. I grew up knowing so much about CF and loving these amazing children. Amazingly we had 2 boys already who tested free with a sweat test and our baby was born a carrier but does not have CF. We felt we had already beaten the odds so, after much consideration, I had a tubal ligation. We knew there was a possibility that our family wasn't all here yet so we began saving for IVF. I feel it's time for another pregnancy yet financially we are not there. Reading Sherry's letter has opened a new door. I have already started the negotiation process. Thank you for your brave stories.

 
Old 10-06-2005, 05:43 PM   #7
Member
(female)
 
Join Date: Feb 2004
Posts: 92
sherry092 HB User
Re: PGD and insurance coverage- help!

Hi- I'd love to hear where you are in the negotiation process. I have a million comebacks if your insurance company questions anything.
Just want to wish you all the best- its an amazing journey

 
Old 12-28-2005, 06:28 AM   #8
Junior Member
(female)
 
Join Date: Sep 2005
Posts: 11
kcgclt HB User
Re: PGD and insurance coverage- help!

I am in the process of trying to get PGD covered by my insurance. Both my husband and I are carriers of CF and have one healthy baby girl. I am trying to explain that I am not trying to get IVF covered just for the sake of getting pregnant but for the prevention of a disease. I am on my third appeal and have been denied coverage so far due to the fact that they simply see it as IVF coverage and are denying it across the board. I have had my OB write a letter explaining the situation and I have tried to be thorough in my explanation of CF/PGD/IVF. Any ideas or thoughts from you would be appreciated since you have had success in this situation. Thank you!

 
Old 12-28-2005, 07:04 PM   #9
Member
(female)
 
Join Date: Feb 2004
Posts: 92
sherry092 HB User
Exclamation Re: PGD and insurance coverage- help!

Here's what I would say:

**Please first make sure that your insurance company fully understands PGD, cut and paste info from a website, anything- and only refer to this process as PGD Pre genetic diagnosis.

In regards to the denial of my PGD claim, please read the follow to further clarify that this is NOT a simple IVF or fertility treatment claim.

My husband and I are not infertile, we were able to conceive our daughter naturally, without any problems. Unfortunately in the process we found out that we are both carriers of Cystic Fibrosis, and with each pregnancy, we have a 25% chance of having a baby born with CF. We were able to beat the odds once, but are now chosing to expand our family in the most responsible way possible. There is a clear difference between needing IVF for fertility, and needing PGD with IVF for medical reasons, so please keep this in mind during the approval process.

I do understand that the cost of PGD is considerable, but also know that the ongoing care of a child with CF far surpasses this expense. For instance the cost of a breathing vest:$15,000- $25,000, lung transplant: $100,000, countless office visits, tune ups, monthly perscriptions for enzymes, ADEK, antibiotics, nebulizer treatments, feeding tubes, etc. Although PGD is an upfront cost, it virtually eliminates the risks of any future burden on you, our insurance company..

There is also a quality of life issue that a price tag cannot be put on. How can we, in good conscience, take the risk of expanding our family naturally, knowing that the science of PGD is available?? How could I explain to my child that CF could have been avoided, but we just couldn't afford it. We never intended on having just 1 child, and its not fair that our family tree ends here, simply because we're not risk takers. PGD is not the way I dreamed of having another child, but how could I put our family through the agony of CF, unnecessarily??

I do know that Anthem Blue Cross covers PGD in certain circumstances such as ours. It is not unheard of for an insurance company to consider the odds and the costs, and the health and well being of their insureds, and to make a decision that is based on common sense. This is why I am bringing this matter to you, the review committee, to see the human side and the financial side, of a very difficult situation. I hope you are able to see pass the initial IVF claim and denial, and really understand what I am asking to do, expand my family through Pre Genetic Diagnosis, and eliminate the chances of having a child with Cystic Fibrosis, and eliminate the financial burden it would place on your insurance company if that should happen.


--- Hope this helps, don't stop fighting!!!!!

Last edited by sherry092; 12-28-2005 at 07:22 PM.

 
Old 12-28-2005, 07:13 PM   #10
Member
(female)
 
Join Date: Feb 2004
Posts: 92
sherry092 HB User
Re: PGD and insurance coverage- help!

Here is an excerpt from a newspaper article that was written on our family, focusing on CF, newborn screeening and PGD. We were able to change Anthem's way of considering PGD and they have now made it a policy. Paste this into your letter, if you'd like. Insurance is a business, why can one do it, and another not. Also inform them that this was a first round approval- if you choose to use this. It was written 9/12/2004



"In the procedure, doctors give female patients drugs to increase the number of eggs they produce. They remove the eggs and fertilize them with sperm. They then wait until the embryos have developed to eight cells. They remove one of those cells to find out if it's free of the defective gene that causes a particular disease. If it is, the egg is implanted back in the mother's womb.

The procedure costs about $20,000, which Anthem Blue Cross and Blue Shield agreed to cover.

Anthem spokeswoman Karin Nobile said it is Anthem's policy to pay for PGD if there is sufficient medical evidence and the genetic disease can be identified in an embryo.

"Our mission is to improve the people we serve," Nobile said. "I'm very glad this person saw that, in word and deed."

 
Old 12-29-2005, 06:26 AM   #11
Junior Member
(female)
 
Join Date: Sep 2005
Posts: 11
kcgclt HB User
Re: PGD and insurance coverage- help!

I cannot thank you enough. I have written similar letters but your information is much more thorough and the details about the cost of treating someone with CF is very helpful. Thank you soooo much. I am anxious to have another baby. I will keep you posted on our progress.

 
Old 12-29-2005, 07:05 AM   #12
Member
(female)
 
Join Date: Feb 2004
Posts: 92
sherry092 HB User
Re: PGD and insurance coverage- help!

I'll keep you in my prayers

 
Old 01-10-2006, 06:11 AM   #13
Junior Member
(female)
 
Join Date: Sep 2005
Posts: 11
kcgclt HB User
Re: PGD and insurance coverage- help!

Tomorrow my husband and I are taking part in a teleconference with our insurance company,their attorneys and doctors. This is part of a second level grievance review. I plan to fight like mad to get our IVF/PGD covered. I just wanted to thank Sherry092 for her help in this matter. Your story is an inspiration to me and your letter was invaluable.
Any more ideas or arguments from anyone are appreciated. I hope to go into this meeting with as much material as possible. The main factor is that my husband and I are not infertile just trying to prevent a fatal disease from being passed on to our next generation. We are both carriers of the delta 508 gene.
Thank you.

 
Old 01-10-2006, 07:39 AM   #14
Member
(female)
 
Join Date: Feb 2004
Posts: 92
sherry092 HB User
Re: PGD and insurance coverage- help!

Oh My God!! I am crying as I type!! I am so happy for you!!

I would definately mention Anthem BCBS paying for this for me and we had NO IVF coverage at all. There is a responsibilty on the insurance company to not just TREAT illness, but to PREVENT it if at all possible. Insurance is a business, if their competitor can do it, so can they. Have them call Karin Nobile at Anthem if they need to. Look up her #

You & your husband would not choose to have a procedure to conceive, so this cannot be considered an easy way out. Your are doing this to prevent your unborn child from having a deadly genetic disease.

They know the cost of treating a child with CF (that is THEIR biggest risk issue) you are totally eliminating this risk, by subjecting yourself to this procedure. It is not fun, its painful & time consuming- but to ELIMINATE risk, this is what you're willing to endure to EXPAND YOUR FAMILY.

The ONLY way PGD can be performed is with IVF- there is no other way. The chances of you getting pregnant on the first try are very high, because you're not infertile- so this probably will not be a procedure that needs to be repeated 3-4-5 times in a row like most infertile couples. BIG SELLING POINT!!!!!!!!!!!!!!!!!!!!

Please ask me anything- tomorrow is a big day & I want to supply you with all the ammo you need. Be strong, you are their client. You are not asking for breast implants, this is not frivolous- this is life & death. I'll check back all day long.

prayers for you

 
Old 01-11-2006, 10:16 AM   #15
Junior Member
(female)
 
Join Date: Sep 2005
Posts: 11
kcgclt HB User
Re: PGD and insurance coverage- help!

We had our teleconference today and both my husband and I fought like mad to make the insurance company understand our situation. We are waiting now for their final decision and will be notified by mail probably by Tuesday of next week. I was able to use the information that sherry092 gave me as well as the article that was written about her family. It was unbelievably helpful. I will let you know how everything turns out and thanks so much for the ammo that I needed to drive home our argument in this case.
I guess it really comes down to dollars and cents in the long run and what an insurance carrier is willing to pay for. I feel like it is a no brainer given the cost of care for a child with CF compared to the cost of the PGD procedure. Unfortunately, I have long since stopped trying to figure out the rationale of most insurance carriers. All I can do now is wait.
Again, MANY thanks to sherry092 for all of her help and good wishes.

 
Closed Thread

Similar Threads
Thread Thread Starter Board Replies Last Post
What Insurance company will pay for Suboxone prescription DTryingMB Health Insurance Issues 8 08-01-2011 01:19 PM
insurance, fmla and a compressed cord happynessa Spinal Cord Disorders 7 11-10-2009 09:13 AM
Finding insurance for pre-existing condition (depression) justanothergrrl Health Insurance Issues 1 10-05-2009 09:09 PM
Another question regarding UA's and Life Insurance applications kim46 Pain Management 11 08-11-2009 10:54 PM
does insurance company have to continue coverage for pre-existing condition? exdepbaby Health Insurance Issues 3 01-17-2009 07:26 PM




Thread Tools

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is Off
HTML code is Off
Trackbacks are Off
Pingbacks are Off
Refbacks are Off




Join Our Newsletter

Stay healthy through tips curated by our health experts.

Whoops,

There was a problem adding your email Try again

Thank You

Your email has been added




Top 10 Drugs Discussed on this Board.
(Go to DrugTalk.com for complete list)
Albuterol
Augmentin
Flonase
Pulmicort
Prednisone
  Tylenol Ultrase
Xopenex
Zantac
Zithromax




TOP THANKED CONTRIBUTORS



Ratatosk (4), pinstripe1981 (1), vampalicious (1), Jess mom (1), LadyGreenSleeves (1), sherry092 (1), Titchou (1), luckydraw (1), Hope1986 (1)

Site Wide Totals

teteri66 (1180), MSJayhawk (1004), Apollo123 (904), Titchou (847), janewhite1 (823), Gabriel (759), ladybud (754), sammy64 (668), midwest1 (668), BlueSkies14 (610)



All times are GMT -7. The time now is 02:17 AM.



Site owned and operated by HealthBoards.comô
Terms of Use © 1998-2014 HealthBoards.comô All rights reserved.
Do not copy or redistribute in any form!