Xiaflex insurance DENIED

[malikan77]

So after waiting over 7 weeks, Dr Lue's office came back and told me my insurance didn't approve Xiaflex.  I have pretty good insurance (Blue Cross Blue Shield) so not sure if this common?  Is it worth pushing the insurance company for approval or is that a waste of time?  Honestly I was dreading the whole process anyway and feel like I can live with my current situation (45-50 degree curvature, manageable pain).  However, it does feel like the Peyronies Disease is slowly getting worse and my plaque area is quite large.   Right now I just do the Pentox, L-Carn, Ubiquinol, L-Arg, Vitamin cycle.  Doesn't seem to help much so would appreciate any other ideas!  

[peter123]

I pray for you and that everyone working and that insurance responsible for the denial will get aggressive and terminal cancer

[Stabler]

Dr Lues office can appeal the denial and they should. Did they mention that they would do that or did they say that you needed to try/fail other formulary medications first? Sometimes when a medication is not in the approved formulary, the plan will want you to try whet they feel is a more cost effective med that they think will do the same thing. That being said THEY are not a doctor and do not know what best will treat you. Ask Dr Les office to appeal.

Stabler

[BrettC]

I too am under Blue Cross / Blue Shield and got a denial for XIAFLEX.  Not sure what to do, but I did ask my Urologist's office to appeal.  And I will do what I have to as well.  

But with the size curve you have Xiaflex should give you great results. Or surgery would too... it sounds manageable, and from what i hear Xiaflex works to straighten curves of 30 degrees pretty well...  

[TonySa]

I'd fight it and add Lue may succeed in an appeal. He's very experienced in xiaflex and will have you add traction which you could start now.

[malikan77]

Thanks everyone.  I called BXBS and they said there are requirements to be granted the Xiaflex prescription and it wasn't clear that Dr. Lue's office communicated these properly.  They sent me the policy and it says you simply must have palpable plaque causing curvature and at least a 30 degree curve.  Since I meet these requirements I'll now have to go back to Lue's office and get them to resubmit properly.  What a pain in the dick  

[Stabler]

Good, the insurance companies all have protocols that they have to have followed, now... Dr Lues office should have known this information so either they have someone new doing the authorizations or they didn't actually send clinical documentation to support the request (which anyone that does this regularly would have done)

Stabler

[malikan77]

Just to follow up on this, Dr. Lue's office did apparently put in the old college try to get this approved.  Apparently since my insurance covers drugs through a 3rd party a medially induced prescription isn't covered. They only cover drugs that are given to the patient to self administer.  Anyone have experience with this?  Sounds like it is fairly common.

[Stabler]

Xiaflex is not a medication that can be self administered and if you have tried/failed all of what they have considered to be formulary medications then an appeal should be approved.. You need to appeal this decision yourself with your insurance company.

Stabler

[malikan77]

Thanks, appreciate the response!

[john.doe.550]

I've had some trouble with insurance.  Worst problem was a doctor representing insurer read my request and denied it.  Turns out, he was not qualified to make judgement on this medical issue. Got the insurance company to agree. Then they flubbed up the prescription approval. They crossed my records with a cancer patient and identified the cancer patient's attending physician.  Was able to get the insurance company to understand this mistake in about a month (that's not long). However, it took 4 months to get the insurance company to understand the treatment dosage they'd approved was for the cancer patient's medication.  In simple volume terms, he would get 50% less medication than i would get.  It really was a battle to get the dunderheads at insurance company to understand they needed to correct this, too.  But, I prevailed and received more xiaflex.  The injections in SEP 2020 were notably effective.  

[Hershel]

I've had BXBS ppo (anthem and now Bxbl of Illinois, who are more difficult) and gotten approvals for three full rounds of xiaflex. Two of the three though had a delay and I had to mitigate by calling both the doctor and the insurer. The doctor had either not supplied enough info or the insurer claimed they didn't get it. The last round took almost three months to approve. Perhaps they don't want to put out the ridiculous sums of money billed (in my case over 300k). Sad to say though after 24 total injections and lots of traction, including restorex on and off, my results are not great. Dr Lue treated me for the second and third rounds. My curvature went from about 40 degrees initially 2 years ago to about 80 after the the first round. Then back down to about 40 after two more rounds. The curve is much smoother, length improved a bit and no pain. Not sure if I'll try again, out of pockets have tripled and have to pay at least 6k to keep going.  

[TonySa]

Malikan, hang in there w the appeal.  Meanwhile maybe add low dose nightly generic cialis to remodel the plaque and traction.  Traction is also now recommended between xiaflex cycles.