The Circles For My Child’s Survival
Warning: This is an outrage post. For my normal readers, I’m sorry that you will see such a raw side to healthcare management. For those who manage chronic care for themselves or other, this may seem all too familiar for you. I’m glad that we have each other in this path.
Alexis aspirates liquids. Since March 2011, she has been able to try honey thick liquids. Apria has provided cases of Nestle Resource Dairy Honey Thick to our house in her monthly shipments. Alexis has had Cigna as her primary insurance and MassHealth secondary.
Apria notified me that Alexis’ Nestle Resource Dairy Honey Thick was denied by CareCentrix because Alexis did not have ‘errors of inborn metabolism’. I did not understand this so I called Cigna to confirm what was the issue. I called Cigna and they confirmed with CareCentrix and Apria that if we got a new prescription from her primary doctor, they would resubmit it.
I got a new prescription for Alexis to get Nestle Resource Dairy Nectar Thick from her primary doctor. In January, Alexis passed her swallow study and now is able to drink liquids that are nectar thick consistency. If the liquid is thinner than nectar thick, Alexis aspirates – which could result in pneumonia and hospitalizations.
My husband faxed the new prescription to Apria.
I called and Apria they said their fax machine was down the prior week and that I needed refax it. My husband refaxed.
I called Apria to ask when we would be receiving the Nestle Resource Dairy Nectar Thick. After waiting on the phone for 45minutes, they said that it was denied by Cigna again and that I would need to call Cigna to find out why they aren’t approving the Nestle Resource Dairy Nectar Thick.
10am Cigna said they didn’t show any record of ever paying for Nestle Resource Dairy Nectar Thick. They said that if it was covered by secondary insurance, that CareCentrix would need to bill MassHealth.
4pm I called CareCentrix to ask them to add Alexis’ secondary insurance so that her secondary insurance could cover the payment for Nestle Resource Dairy Nectar Thick. They said that because Cigna is 100% payor, their contract does not allow them to add a secondary insurance to Alexis’ account.
4:15pm I called Apria back and asked them to add Alexis’ secondary insurance for this item. They said because Cigna is 100% payor, their contract does not allow them to add a secondary insurance to Alexis’ account. They did say we could pre-pay for Nestle Resource Dairy Nectar Thick and then seek reimbursement personally from MassHealth. This didn’t make sense to me, since from 2011 to 2013, Apria provided the Nestle Resource Dairy Nectar Thick each month.
4:30pm I called Cigna back and asked them why this changed in January. It didn’t make any sense that Nestle Resource Dairy Nectar Thick was approved from 2011 to 2013 and now it suddenly changed. Nothing has changed in Alexis’ healthcare or medical status. Gayle McGee in the Cigna Texas office spent 2 hours working on this last night and is going to continue working to investigate this.
Alexis has multiple congenital anomalies, including risk of aspiration based on her swallowing issues. This is well documented and her doctors can provide any documentation that may be required to explain her medical issues.
June 17: Care Centrix person called from 913 749 5697 asking me questions about Alexis’ new formula that she’s requesting. I described that we still need the Pediasure 1.5 Cal and as well the new formula Nestle Resource Dairy Nectar Thick.
June 18 1pm: Apria called to inform me that Care Centrix called them and they are no longer covering Alexis’ Pediasure 1.5 Cal formula.
1:20pm: Called Care Centrix, they can’t do anything. Need to call Cigna. Call to Cigna says I have to get all of her Pediasure 1.5 Cal formula re-certified.
Alexis will end up in the hospital without g-tube food. She will aspirate liquids if she does not have the right mixture of thickened liquids. That will also result in a hospital stay. Momma Bear on a path and it’s not pretty.