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Technical assistance nets a health plan to cover needed infusions

Most of the names in these stories have been changed to protect privacy.

Jenna Marie Wilder has chronic inflammatory demyelinating polyneuropathy (CIPD). The neurological disorder causes weakness and impairs sensory function in her legs and arms. Until Medicare kicks in, Ms. Wilder has healthcare benefits through her former employer’s self-insured health plan. Under the Employee Retirement Income Security Act of 1974 (ERISA) a self-insured plan is not subject to the state consumer protection laws that govern health plans.

With intravenous immunoglobulin (IVIg) infusions, Ms. Wilder was less dependent on her wheelchair and could function better. But when the health plan denied payment and prior authorization, the treatment stopped. She could not afford $20,000 a month. Her level of functioning dropped.

A senior attorney in the Los Angeles office researched and reviewed Jana’s records, which showed that:

  • IVIg infusions are a standard, first-line treatment for CIPD; and
  • There was an earlier diagnosis of lupus (SLE).

At the attorney’s recommendation, Ms. Wilder had her treatment team write a report detailing:

  • The basis for the CIPD diagnosis;
  • Why the earlier diagnosis of SLE was incorrect; and
  • The positive results from the IVIg infusions.

With the Los Angeles attorney’s help, Ms. Wilder convinced the health plan to redo the denial as an initial determination and approve it.

Now that she is getting IVIg infusion treatment again, Ms. Wilder has regained the ground she lost while she could not get the infusions.