Anthem California denial overturned by California Dept. of Managed Care

[asdsrfr]

I have applied for Xiaflex coverage through my carrier--Anthem of California. They denied multiple times and subsequently on appeal. Never was it an issue of me not meeting criteria for Xiaflex. They simply will not pay for it for Peyronies as "Not Medically Necessary" for any patient. Fortunately in California you can appeal to the Department of Managed Care and their decision is final and binding. They overturned the denial and ordered Anthem to cover the cost of Xiaflex. It's a bit of a process to go through but honestly easier than dealing with Anthem which was like talking to a wall!

[kuaka]

The worst part of being a "non life threatening" condition can be convincing insurance accountants that it is medically necessary.  If not for this, I would have suggested you take out a life insurance policy with the same company that doesn't exclude suicide and that may help convince them that it is.  Congratulations on the successful appeal..now here's knocking on "wood" that you have success with the treatment itself.

[hope4all]

This is great news, asdsrfr! On various threads, I've been dispensing this exact advice...so glad there is tangible proof that it worked!  Anthem BCBS is one of the biggest insurers in the U.S.

There's no doubt Anthem has denied Xiaflex for countless Peyronies suffers and they will continue to do so regardless of one overturned decision such as yours. That is why ANYONE HERE WHO HAS RECEIVED the over general and nebulous "Not Medically Necessary" denial should appeal. Whenever you receive this denial your chance of overturning it is VERY high when you involve your doctor or complain to the State Insurance Commissioner.

For profit and even non-profit health insurance companies here in the states are very liberal when it comes denials and unfortunately most people don't question it. Question EVERYTHING your insurance company denies or reduces it's benefits for some reason.  20% of the time it's human error, another 20-30% is an automated denial based on diagnosis alone. These are claims that an adjuster doesn't even look at...the computer just denies it for the procedure code or diagnosis code or both.

If you notice others here on the boards having issues with their insurance maybe you can give them specific advice on how to appeal.  Thanks for letting us know, and good luck with your treatment!
Hope4all