tenncare denied my appeal, I'm pissed.

[MotherWhimsey]

So I have a really really really crazy severe anaphylactic allergy to latex and rubber. Like I don't have to be in the room with it, I just have to be in a building that shares air ducts with another office that uses it and I'll go into shock. So I got pregnant, got on state insurance, and got my doctor to prescribe a homebirth. actually I didn't have to even ask him, he told me that unless there was a problem with the baby, giving birth in the hospital was just way too dangerous, so I need to have a homebirth. Hey, cool with me, no problem there. Well tenncare denied it. I appealed. They denied it again. I just got the letter. I am so upset. The first time they denied it they just said that the midwife was an out of care provider, and that I could get ob care in network. this time they wrote back "A home delivery for someone with a latex allergy is not a safe and effective plan of care. The best care for you would be to be in a hospital or a birthing center to have your baby. This means that you will have proper safety measures for your latex allergies." Okay, this pisses me off. Apparently giving birth in a home that is totally rubber free and safe for me to be in, with a certified nurse midwife is not safe. But putting my life at risk to get ob care is totally safe. I mean they can treat my allergy with epinephrin in the hospital right? I mean who doesn't want to get intubated during delivery, take a drug that puts your heart at risk, be vomiting violently, having constant explosive diarrhea, heart arrythmia, and difficulty breathing. Sounds like a joyful and safe hospital delivery to me. But you know, anaphylaxis can be treated in a hospital so it's all okay, at home it would just be prevented. ARGH!!!!!!!!!!! I am so so so f%$#ing mad right now. I WILL NOT PUT MY LIFE AND MY BABY'S LIFE AT RISK, just because you guys are stupid dumb sh*&s that don't get it. So, i can't afford the midwife, but will give birth with her at home anyway. It sucks that if you're poor you don't have the choice to do something that is better for your health. So I'm appealing it again, cause quite frankly I like having money to buy groceries. So will someone help me formulate another appeal? I think I'm going to do this one in writing.
They want me to go to the hospital wearing a charcoal filter mask to the delivery area to see if I have a reaction. Now there are two flaws to this logic, 1. I will not go somewhere and see if I die just so I might be able to go there and die at a later date. that is the dumbest test in the world. might as well test a kid with a peanut allergy by feeding them peanuts. So that is just too much of a risk. 2. I have already had two reactions at the hospital when I went to get an ultrasound. and also twice when I went to the OB at the begining of the pregnancy. So I think that should suffice as evidence of a reaction at the hospital or the ob.

also, they got my records of my daughters birth from the OB. She was born in a hospital, and I was not yet anaphylactic to latex. That just happened in January of this year. So that is not a fair thing for them to say. basically they said "well you had her in a hospital two and a half years ago and there was no record of a problem, so we don't see why there would be now."

Is it evil of me to hope they all become horrendously allergic to something as universal as rubber, and have to become shut ins, and not be able to get any health care cause they're poor and can't find any doctor that's totally latex free? cause i do hope they have to. A little anaphylaxis might do them a little good, make them more empathetic.

Oh yeh, and this would be WAY WAAY WAAAAAAAAY cheaper to have a homebirth than deal with shock and birth in the hospital. So what the hell is their beef?

okay I think I'm done now. I feel a little better. I'm still pissed though. thanks for listening.

[Wolfmeis]

They are so evil.

I will be back with something intelligent later, but basically I am too P&ssed off for you right now.

This is a homebirth issue for them, not an allergy issue. UGH!

[adtake]

I am so sorry you are having Tenncare problems! They can totally suck!!

Do you have a case manager with them or are you just going through the appeal center? What you might want to do it call and get a case manager, sometimes that will help the situtaion out.

Have you thought about a UC? I am scared at the thought (myself), but it could be a perfect option for you. Is Tncare covering prenatal midwife care? We just had #3 at Lisa Ross in Knoxville and had to go through way too much paper work to get approved. (private insurance) but I am pretty sure they take TNcare.

Hang in there! I know you are stressing big time, but you do have a little time still.

Sending support and thoughts your way!!

ps..where in TN are you

[MotherWhimsey]

smlwieber, thanks for the tip about the case manager. We have been going through the appeals center. So I'll definately give that a try. I live in Cookeville, and looked into the birth center in Knoxville, even though it's 2 hours away (and my first labor was 4 hours), but they are not latex free, so it's just as dangerous for me as a hospital or dr.s office. They do take tenncare though. And I wouldn't mind a UC, but my husband would probably flip out. Right now family memebers are all going to contribute to pay the bill I think, but that just makes me feel like a mooching shmuck, you know? But the doctor said that regardless of the outcome with insurance, I do not need to go to the hospital unless someone's life is at risk. So sometimes you just gotta suck it up. I just hate this though.

[adtake]

I work with special needs families and have learned the case manager trick! I hope you get some better responces that way. Just make sure you have all your paper work together, *the dr saying no hospital birth, * the orignial diagnosis of latex allergy, *all the costs involved,....

and good luck! hang in there!!

If I was closer I would come help!

keep us posted!

[Electra375]

The trick is getting to the top past the appeals center (private ins denial of hb, but I finally got them to pay).
Also, you have your allergy documented with the appropriate medical test etc. And documented that it was not sever in nature at your last birth, but now it is.

Get to someone above the appeals center.
Make sure they get all of your documentation and recommendation to not be in a hospital and why.
Then if they continue to deny coverage, get it in writing.
Then go back to above appeals center and state that you want in writing that they will ensure that you will not die going into a hospital against the advice of your allergist and OB (spell it out again bold type etc) and if you do die your children will receive $10million dollars a piece for their care until college as a settlement for your death.

I wrote many letters, filed copies, upon copies of the same stuff and finally through an e-mail I got the phone no. to the person on the top whom the go between person had been relaying information to. Well, I called the top and she say it's covered, you'll receive your reimbursement check in 2 wks -- I did. I should say also it took 1 year to do this.

[shelbean91]

I had to go through the appeals process for a procedure I had (correcting vericose veins). I got a rejection b/c the procedure was medically necessary, but 'experimental'. The doc sent the paperwork back to show that it wasn't experimental, so I got a rejection letter saying 'ok, it's not experimental but it's not medically necessary'. So, the 3rd and final level of appeal was to the state board (not in the actual insurance office, like the first 2) and they found the ins company had to pay.

Hopefully, you have the option for a 3rd party appeal and they'll settle it in your favor. Good luck.

[MotherWhimsey]

well I have a hearing in front of a judge on Oct. 25. Maybe this will help. So now I just have a lot of stuff to gather up to be prepared for the hearing. any advice? I figure if I'm not going to get what I need, at least I can be as big a pain in their asses as possible.

[jaidymama]

I would get your doctor to advocate for a homebirth since that is what she?he? recommended in the first place. I don't know about hte appeals process, but I would get as much documented stuff together as possible... Do you get a lawyer for this or are you presenting all this by yourself? It would seem insurance companies do not always have the best interest of their patients in mind (rather their pocket book)... anyways, if you can't get your doctor to go with you or submit a statement to the Judge then perhaps get copies of all of your medical records that documents this allergy. If you have had a test, or ended up hospilatized from any of your actions I would think those things would be good to take with you.

You've probably already thought of these things. So all I can do is send good thoughts your way. Good luck!

Oh, and I was thinking... I don't know when you're due date is... but I would try to avoid getting overly stressed out (although it might be difficult to do) it might be harmful to your health... And that means the insurance company is putting you in that position. Sorry about all this.