Appeal Letter to Horizon Blue Cross Blue Shield of New Jersey

Here is the appeal letter I faxed to Horizon yesterday with copies of all John's physical and occupational therapy notes and an article that I hope helps.  Here is a link to the article:  http://rockcenter.nbcnews.com/_news/2012/04/24/11371569-health-care-laws-leave-hospitals-overwhelmed-by-permanent-patients?lite

Please wish John luck!!

January 15, 2015

Horizon BCBSNJ Appeals Department

Main Station PP-14E
P. O. Box 420
Newark, NJ  07101-0420

RE:  John Krostek #3HZN47747820

Dear Sir/Madam:

I wish to pursue an expedited external appeal for the denial of benefits for subaccute rehabilitation for my husband John Krostek.  My insurance policy provides for up to four months per year of subaccute rehabilitation or skilled nursing care so coverage for this benefit is not an issue here. 

On October 26, 2014, my husband, John Krostek, suffered a stroke.  John has been independent and has been self-employed most of his life.

I think it should be required to see pictures and videos of the patients when you are making majors decisions about their lives, so here are pictures I took of John in early December.  I wish I had a picture of what he looked like in early November when he couldn’t even sit up or turn over on his own so you could see the progress he has made. 

On Father's Day in 2013, John had a lacunar stroke.  His right side was affected and he needed physical therapy, but it was mostly his balance and speech that gave him trouble. John was denied physical therapy several weeks, and had I known I could appeal, I most definitely would have because he would have recovered a lot faster with physical therapy.  John is very strong so after several months, he was walking without assistance and a barely noticeable limp.

Although John’s speech wasn’t affected this time, this stroke affected John's right side again.  His right arm was weak but his leg was far worse than last time. John was in the hospital for 10 days by in mid-November, he still couldn't even turn over in bed or sit up by himself.  On top of all of this, John was diagnosed with prostate cancer and was just about to start 44 radiation treatments when he had the stroke.  Luckily the cancer was caught very early because I noticed that he was urinating more than usual. 

I arranged for John to see a urologist, and when they found his prostate was enlarged they performed surgery and the biopsy was positive for cancer.  The doctor said that it usually isn’t caught this early.  Since it didn’t even show up in the bloodwork he had ordered, he said John was very lucky.  I wanted you to know this because I want to be sure that John is not being refused treatment he needs because anyone thinks he will not recover from cancer.

John started his radiation treatments in November.  He has about 10 treatments to go and will be finished in two weeks.  In spite of the radiation and the exhaustion he sometimes feels, John has had physical therapy twice a day for about six weeks and has made dramatic progress.

Horizon Blue Cross Blue Shield of New Jersey first denied John’s physical therapy on December 4^th because it wasn’t deemed medically necessary.  He was really starting to improve when after a month of physical therapy, he was written off at 57 years old to be left in a wheelchair.  Dr. Luhana, John’s primary care physician at Lincoln Park Care Center spoke with a doctor at Horizon and physical therapy was resumed.

Physical therapy was again denied on December 19^th because it was again concluded medical necessity had not been established.  This time, I found out that I could request a second level expedited appeal, and a conference call was arranged by Horizon which took place on December 23rd.  

During the conference call, the Lincoln Park Care Center staff were very supportive and felt that John was making good progress. I explained that I have been with John for 31 years, and married almost 26 years.  I said that I am very committed to John and I will fight for him to walk again.  I told them I visit John 2 to 3 times a week and every time I see him, I see improvement.  It was noted that John had started walking 2 feet twice a day with moderate assistance, and at the time of the conference call he was walking consistently 20 feet twice per day with minimum assistance.  I would like to note something I didn’t think was necessary to say but John wasn’t really walking two feet.  He literally had to be lifted up from the wheelchair to the walker, and had to be supported by two people to safely stand and then he could only shuffle his right foot.

I brought up some of the areas I saw where John had improved:  he started pulling himself up from the wheelchair to the walker, and by then, he could get up by himself without pulling himself up to the walker, and without assistance.  I was able to get him in my car but he still couldn’t walk even with the walker without close supervision, and it wasn’t felt he was ready to tackle steps which limits where I can bring him.  

We must have convinced the two Horizon doctors and a nurse on the conference call that John was a fighter and that he needs physical therapy to help him walk again because I got a call that day that we won the appeal, and that John’s physical therapy would be retroactive to December 19^th and continue until January 5, 2015.

On January 5, 2015, the day after John's 57th birthday, I was again notified that his physical therapy was again denied.  I requested another second level expedited appeal and a conference call was again arranged by Horizon which took place on January 7^th.  Again, there were two Horizon doctors and a nurse on the conference call.  This time, I didn’t feel as hopeful for two reasons. 

The first reason I wasn’t as hopeful was that only one person from the original conference call was on the second conference call.  I got flustered because I had to start from the beginning and since they said we only had 5 or 10 minutes to talk, I forgot some of the important things I said during the first conference call.  How can they expect to understand what someone is going through if there are different people reviewing the case every time, and we are given only 5 or 10 minutes to talk? This is unreasonable since we are talking about someone’s life here.

 The second reason I didn’t feel hopeful is that there were only two people from Lincoln Park Care Center on the call this time.  The person I thought was a physical therapist from Lincoln Park Care Center was speaking so low I could barely hear him and I didn’t get the same feeling of support as I did during the first conference call.  He said John was walking 25 to 30 feet twice a day through January 5^th, and was about the same as before the last second appeal. 

I interrupted and said that I had to disagree with him because I was on the first conference call when they said John was only walking 20 feet twice per day.  A little over a week later, John walking consistently 30 feet twice a day with minimum contact guard which is 25% better in a just over a week.  I also said that I was told before the second conference call that John had not plateaued, and that he was still showing improvement.  I later found out that the physical therapist was not on the conference call which explains the miscommunication. In any event, I received a call later that coverage was continued through the completion of the appeal but coverage remains denied from January 8^th forward.

I am attaching both the physical and occupational therapy notes from John’s medical records that prove my statement above that John didn’t start walking 30 feet until January 1^st which contradicts what the representative from Lincoln Park Care Center said on the conference call.  In fact, per the medical records, John went from walking 20 feet twice per day to 30 feet twice per day with contact guard assist, and 25 feet wasn’t even mentioned in the notes.  Obviously even though Horizon staff had received these notes by fax for the call, they didn’t bother to check my statement and denied further coverage.

It is what was in the letter upholding the denial dated January 7^th that disturbs me most.  The letter states, “You have made little progress since admission on 11/5/14, when you were walking several feet with assistance and a rolling walker, to the present time when you can only walk 20 to 30 feet under the same conditions.  Your ability to participate in physical therapy continues to be limited by frequent bouts of fatigue.  Your ability to benefit from inpatient therapy is severely limited by your medical condition and would not be expected to improve to a significant degree in a reasonable period of time.”

This statement is both untrue on so many levels, and is unsupported by Horizon.  Maybe Horizon should video tape patients when they first start physical therapy and then regularly thereafter to see the improvements.  I don’t know how fast Horizon expects patients to improve but most of them do not have the strength and speed of Superman, especially after a stroke.  Although John was tired from radiation treatments, he only missed 2 days of physical therapy because he had CT SCANS with enemas, etc. on those days. 

                       
I have also attached notes from John’s medical records since the last conference call that prove the above statement taken from Horizon’s letter of January 7^th is blatantly false.  On January 9^th, John started walking 40 feet twice a day with contact guard assist and by January 14^th, he was ambulating consistently with close supervision 40 feet twice a day.  These notes not only show consistent improvement, they also show that in the two weeks from January 1^st to January 14^th, John is more than 50% better than he was in the last two weeks of December.

I believe the medical records prove that John has made tremendous progress, despite going through radiation at the same time as physical and occupational therapy which contradicts the denial letter of January 7^th.  In fact, the records directly contradict Horizon’s statement that John “would not be expected to improve to a significant degree in a reasonable period of time.”

Even so, there is still medical necessity for physical therapy since John still cannot walk one step without a walker, and he has not been approved to try to walk up even one step yet.  He cannot get his pants, socks and shoes on himself.  He is incontinent due to the radiation, and can't make it to the bathroom. 

So I ask you, “How can Horizon deny John benefits that are medically necessary and covered by my “paid” insurance benefits if he is to walk again on his own?”

I have been paying insurance premiums for 40 years, mostly to companies that offered Horizon as their medical insurer, and I will fight this to get John a covered benefit that he needs.  Since Horizon’s last denial on January 7^th, I wrote a blog called “Shame on Horizon Blue Cross Blue Shield of New Jersey for Denying My Husband Physical Therapy After Recent Stroke” that I shared with my 510+ family and friends on Facebook, on Google, etc. asking them to share it with their family and friends.  I added another post called “An Update on Horizon Blue Cross Blue Shield of NJ’s Shameful Denial.”   I just checked and the blog has gotten over 1,200 views in less than a week.

I also sent this story to Fox Hall of Shame, and I have been offered help from many friends writing to legislators, the governor, the newspapers, the Better Business Bureau, the Department of Health, and whomever else I could think of to try to help John get subaccute physical therapy.

Finally, I am enclosing a copy of an article entitled, “Health Care Laws Leave Hospitals Overwhelmed By ‘Permanent Patients’.”  This article discusses people like John who become permanent patients because they cannot pay for the skilled nursing care they need where they would get more appropriate rehabilitation.  The end result?  It would be cheaper to send these patients to the Ritz Carlton where they could get room service all day. A skilled nursing facility (like Lincoln Park Care Center) would have cost a fraction what Medicaid ends up paying.  Although we have Horizon, it does no good if they continue to deny coverage.

                                                                                                                                 
After being a customer of Horizon for many, many years, I say, shame on you Horizon Blue Cross Blue Shield of New Jersey! 

Thank you, in advance, for reading this letter fairly and impartially.

Very truly yours,

Catherine F. Krostek

/cfk

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