Retinal disorders are conditions that affect any part of the retina, either mildly affecting vision or being so severe that the condition can lead to blindness. Most retinal disorders can be prevented if they are identified and appropriately treated early on. Unfortunately, retinal disorder treatments denied by insurance are all too common, leaving patients frustrated and frightened about the potential consequences of not getting the most up-to-date treatment. If you find yourself in such a position, it is essential that you speak to attorney Scott Glovsky. Scott has been helping people in situations similar to yours for many years. He believes passionately in your right to have someone in your corner who is committed to fighting for justice on your behalf.
Why Might Your Treatment for Retinal Disorder Be Denied by Your Insurer?
In some instances, a denial of your treatment for a retinal disorder is nothing more than a simple error that can be easily corrected. The treatment may have been miscoded or you may not have provided all the required information. In other cases, there may not have been a required prior authorization or referral, or your treatment may have inadvertently been from an out-of-network provider. These denials can often be reversed by correcting the underlying problem. Other times, a retinal disorder treatment denied by insurance could be the insurance company balking at the cost—and cloaking this behind such phrases as “not medically necessary,” or asserting the drug is “experimental,” or “investigational.”
While health insurance companies say they do not interfere with the professional judgment of a physician, the reality is often quite different. Health insurance companies are businesses that care deeply about their financial bottom line. In other words, they strive to make a healthy profit from year to year. To this end, they routinely deny treatments that are expensive, requiring the insured to try many other treatments before they will pay for the more expensive one—or simply denying the treatment altogether. When a treatment or drug offers your very best chance for recovery from an illness or disorder, it can be disheartening to have your insurance company deny your claim. Attorney Scott Glovsky never takes “no” as the final answer, and never hesitates to go up against a large insurance company, fighting for your rights, your health, and your future.
What Should You Do if Your Health Claim is Denied?
If your retinal disorder treatment has been denied by your insurer, you do have options. According to cancersupportcommunity.org, in 2019 40.4 million health insurance claims were denied, yet only .02 percent of those denied claims were appealed, even though people who do appeal often obtain favorable results—as many as 60 percent. Filing an appeal following a retinal disorder treatment denial is your right. The appeals process begins with an internal appeal where you ask your insurer to reconsider its decision.
You have six months from the day you learn of your retinal disorder treatment denied by insurance to file an appeal, however, it is certainly in your best interests to appeal as quickly as possible. If waiting for an extended period of time could cause more harm, you can file an expedited appeal. If your internal appeal is unsuccessful, you can file an external appeal. An external appeal goes to an independent entity, asking it to look at the facts of the claim. Generally speaking, you have four months from the day you learn your claim was denied, in which to file an external appeal.
What Insurance Companies Are Most Likely to Deny Your Retinal Disorder Treatment?
Although any insurer can deny a retinal disorder treatment, some insurers may be more likely than others to do so. Some of the California health insurance companies known to deny necessary treatments include Anthem Blue Cross, Blue Shield, Health Net, Oscar, Kaiser, Regal Medical Group, UnitedHealthcare, Aetna, and others. Attorney Scott Glovsky has successfully challenged all of these insurers during his time in practice and has no issue taking on a multi-billion dollar company on behalf of his clients.
What Are Some of the Most Common Treatments for Retinal Disorders?
Age-related macular degeneration and diabetic macular edema are just two types of retinal disorders—and are the leading causes of blindness in adults in the United States. These specific retinal disorders can often be managed with relatively new drugs called Vascular Endothelial Growth Factor inhibitors—like Vabysmo and Eylea.
There are many treatments associated with retinal disease, ranging from preventative therapies to surgical options for retinal detachment, laser treatments to seal leaky blood vessels, and injections like Lucentis and Avastin to stop abnormal blood vessels from growing in the retina. Laser surgery, freezing treatment, and other surgical options may be able to fix tears or breaks in the retina.
Inherited retinal diseases can be caused by single-gene mutations and currently affect at least 200,000 people in the United States. Gene therapy has advanced significantly over the past decade, with significant recent progress made in gene therapy for inherited retinal diseases like retinitis pigmentosa, macular dystrophy, X-linked retinoschisis, and choroidal dystrophies. Gene therapy is, as you might expect, expensive, so the treatment may be denied by many insurers. Cost is often the defining factor for retinal disorder treatments denied by insurance.
Vabysmo costs about $2,315 per injection, and Eyela costs about $1,957 per injection. Since Avastin costs much less—but also has much less impressive results—insurers are likely to deny the more expensive drugs. It can be extremely disheartening to have a treatment that could potentially “fix” your retinal disorder denied, but the Offices of Scott Glovsky can help.
How Can Your Doctor Help You Get the Retinal Disorder Treatment You Need?
Getting your doctor involved in the process can often help you get a reversal on the retinal disorder treatment denied by insurance, and this may be the first avenue to try. Your doctor can send a letter to your insurance company that explains why you need or needed the treatment. This letter should be sent to the address listed in your plan’s appeal process and you should retain a copy of the letter for your files. Your doctor may also request to speak with the medical reviewer of the insurance plan as part of a “peer-to-peer insurance review,” in order to challenge the decision.
How Can the Law Offices of Scott Glovsky Help a Retinal Disorder Treatment Denied by Insurance?
Fighting an insurance company can be exhausting; health insurers will generally make the appeals process as difficult and taxing as possible so you—and others like you—will give up. For many, it is simply easier to give up and accept a lesser treatment or medication, pay out of pocket, or go without the necessary drug or treatment altogether. You don’t have to accept any of these options, because attorney Scott Glovsky is ready to fight the fight for you.
It’s important for you not to give up. You only need one person who truly cares about you and your case and will stand strongly by your side while going to battle on your behalf—that person is Scott Glovsky and his legal team. Our victories have impacted policyholders across the state of California because sometimes we force insurance companies to change their behavior. Contact the Law Offices of Scott Glovsky today.