insurance coverage for DrLerner labwork, Rx, etc

Discussion in 'Fibromyalgia Main Forum' started by ethermom, Jul 27, 2008.

  1. ethermom

    ethermom New Member

    Hello! Some of you have been helpful in directing us to Dr Lerner, and I'm hoping that you may have some ideas for obtaining coverage.
    I am the subscriber, and we would like to take our son to him. I've started working with a kind case manager at my insurance (Cigna) and also have a helpful HR person at work. Dr L. is not in-network for Cigna, so we are going to see if another in-network infectious disease specialist within a reasonable radius of home address would treat, and what that "treatment" consists of, and perhaps get a referral to him from this provider after a visit if necessary. Or, if no one will treat, then we may be able to get a referral thru our PCP to Dr Lerner. That may cover the office visit.
    The case mgr. has also consulted with her medical director, who referred her to the Cigna Healthcare coverage Position paper; it appears that many of the tests likely to be ordered by Dr. L(viral serologies, HHV, cytokine etc), are not covered, "as they are considered experimental, investigational or unproven when used for this indication". The next paragraph states that several types of treatment, including antiviral therapy, graded exercise therapy, and cognitive behavioral therapy, are considered the same. The rest of the document is a review of the literature, references, etc.
    So, how does one get around this? Per my call to his office, Dr L does accept BlueCross and Medicare, so I'm assuming part of the labwork/treatment/ office visit costs are covered by them, but knowing about that from any of his patients would also be helpful. Did you encounter this problem, and how did you work thru it? We've been struggling with CFIDS for 6 years; I'm in the beginning of this specific part of the journey, and am wondering how to get there! Thank you for your words of wisdom! Kris
  2. ethermom

    ethermom New Member

    Hi, Kelly,
    Well, don't be impressed by our insurance know-how yet! (insert HAHA icon here)

    I assume that you are getting help from Dr Lerner from the length of time you have been seeing him--that's great! Do you know if he is biling them under the CFIDS diagnosis, or another one?

    Yes, the Cigna CFIDS position paper says that all those tests are experimental and not covered with a CFIDS diagnosis. So we have to find a work-around, perhaps by using another diagnosis? Dr Montoya's might be possible, and perhaps Dr Lerner uses specific diagnoses (other than CFIDS) to justify the coverage. I will ned to call his office again about that.

    Our son did test positive to mycoplasma before, but had walking pneumonia about 8-9 years ago; I asked his Dr at the time and was told it is very common to have + results for mycoplasma,. I will need to check on the actual titer, if done--it was several years ago, and so many tests have been dead ends that we stopped saving all the results but can get them again.

    Thank you very much! Does anyone else have any suggestions? Kris

  3. acer2000

    acer2000 New Member

    When I was seeing Dr. Lerner, he didn't take my insurance either. I had United Health. I have a couple of comments. First, if you have a PPO, they will likely pay for him at whatever "out of network" rate you have in your plan. In mine, it was 70%, so when I submitted, they re-imbursed me for that amount for the office visits.

    Next, for labs, he uses Labcorp and basically does HHV6/CMV/EBV titers and sometimes other tests. Labcorp takes almost all insurance, so you will probably be covered there.

    The other tests are done in conjunction with Beaumont hospital, so they may participate, even though he doesn't. I know I had to get a CT scan and United Health paid for it in full because it was done at Beaumont hospital, even though Dr. Lerner didn't take my insurance.

    Finally, once you are on treatment, the main cost will be the RX, which if you have prescription insurance should probably be covered, even if Dr. Lerner doesn't take your insurance for his office visits.

    Dr. Lerner doesn't do cytokine panels and other more experimental tests. So you don't have to worry about that stuff. He is also pretty much a traditional doctor and doesn't RX a bunch of expensive supplements as part of his protocol. He gives you a list of vitamins you can take if you want, but he doesn't specify some designed brand that you can only buy through him, etc.. like some "CFS" doctors seem to do.

    Also, with respect to what CIGNA covers for "CFS", don't go into it with that DX already. Go into it seeking the "cause" of the chronic fatigue. Once he finds your cause (according to him) he will DX with the correct code for the infection he is treating. He doesn't DX you with "CFS", its always "life altering fatigue due to X", where X is HHV6, CMV, EBV, Lyme, mycoplasma, etcc... whatever he decides.

    Unfortunately I went to him and he DX me with HHV6 but I didn't have any response to Valcyte and ultimately couldn't tolerate it due to liver enzyme elevations. Hes a good doc, but I do think hes a little more, shall we say, optimistic about his success rate than he should be. But if you respond to his treatment, you respond to his treatment, so its worth a shot!
    [This Message was Edited on 07/27/2008]
  4. ethermom

    ethermom New Member

    Thank you for your comments--I'm cutting and pasting them all down, as I have a conversation with the case manager tomorrow. Does anyone else have helpful info? BUMP. Thanks! Kris

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