Shame on Horizon Blue Cross Blue Shield of New Jersey for Denying My Husband Physical Therapy After Recent Stroke

On October 26, 2014, my husband, John Krostek, suffered another stroke.  John has been independent and has been self employed most of his life.  He suffered a ruptured brain aneurysm on August 2, 1998 and although he had some brain damage, with physical therapy, John was physically back to himself within six months.

Everyone says John has nine lives because he has had a lot of health issues over the years but he always fights his way back.  On Father's Day in 2013, John suffered from a lacunar stroke.  His right side was affected and he needed physical therapy, but it was mostly his balance that gave him trouble, and after several months, John was walking with without assistance and had a barely noticeable limp.

This new stroke again affected John's right side.  His arm was weak and his leg was far worse.  John was in the hospital for 10 days and in mid-November, he 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.  

John started his radiation treatments in November and has less than 20 treatments to go.  In spite of the radiation and the exhaustion he sometimes feels, John went to physical therapy twice a day for about a month and has made dramatic progress.  I visit John 2 to 3 times a week and every time I see him, I see improvement.  John can now get up by himself and swivel around to get in the wheelchair.  I am able to get him in my car but he can't walk even with the walker without assistance, and he hasn't been ready to tackle steps which limits where I can bring him.  

A recent picture of John

Then the unthinkable happened...Horizon Blue Cross Blue Shield of New Jersey decided to cancel John's physical therapy the week before Christmas because they felt it wasn't medically necessary.  Thanks for the Christmas present Horizon!   I told them I would fight this so after the first level appeal was not approved, I requested a second level appeal which took place on December 23rd.  I convinced two Horizon doctors and a Horizon nurse on a conference call at work that John was a fighter and that he needs physical therapy to help him walk again.  

Horizon gave John two more weeks of physical therapy but one week was retroactive so he really only had about 10 more days of physical therapy.  On January 5, 2015, the day after John's 57th birthday, I was again notified that his physical therapy was denied.  Happy New Year and Happy Birthday to John!

Horizon ruined our Christmas and New Years holidays and John's birthday in slightly over a week!  Lincoln Park Care Center filed a second, first appeal which was again not approved and I requested a second, second appeal which was again held by conference call while I was working yesterday, January 7th. One of the doctors was the same as the last time but the other doctor and nurse were different.  How can they expect to understand what someone has gone through if there are different people reviewing the case every time?  I got a call late yesterday that the second, second appeal was not approved and I will have to appeal by letter.

I told them that I have been paying insurance premiums for 40 years, and that I would fight this to my last breath.  I also told that that I will write to my legislators, the governor, the newspapers, the Better Business Bureau, the Department of Health, and whomever else I could think of to try to help me if they do not continue John's physical therapy.

John has made tremendous progress in six weeks despite going through radiation treatments at the same time.  However, John still cannot walk one step, even with a walker, without assistance.  He has not been approved to try to walk up even one step because Lincoln Park Care Center doesn't think he is ready 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. 

It is unbelievable that even though John has not yet plateaued with his physical therapy, Horizon has discharged him as of today, January 8th, because their brilliant medical staff feels it is not medically necessary.

When I broke my leg very badly 10 years ago, I had 16 weeks of physical therapy.  Why was it medically necessary for me and not for John?

Please help me share this story.  I will be posting this on my Facebook page so that my 500+ family and friends can share it with their families and friends.

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