So my doctor's request to send me to the Cleveland Clinic has been officially denied. That means it's time to start the fight on my own. This is just a rough draft of the first of many tactics I may need to use. I will write them a letter every damn day if I have to.
To Whom It May Concern,
My name is Allison _________, and I am writing on my own behalf, concerning an appeal from my physician, Dr. D________. Our appeal asking Cigna to cover a visit to the Cleveland Clinic has been denied, so I have decided to take my own initiative and hopefully, clarify some misunderstandings.
First and foremost, the decision to send me to the Cleveland Clinic was a mutual one between my doctor and myself. After being under his treatment for a year and a half, and not healing as expected, Dr. D_______ suggested specialized care, to which I agreed. I did not ask to be referred out of network, but both my physician and myself felt like we were out of options. I will get into the specifics of his treatment later. We have heard differing things from Cigna regarding the appeal. First, we were told that an initial denial was given because no medical records were sent along with the letter from Dr. D______. Then, we were told that any additional information would not do anything to help my appeal. However, I am still gathering all of my medical records for you to review.
On June 12, 2003, I was the seat belted passenger in a motor vehicle accident. We were at a dead stop, waiting to turn left when a semi hit us from behind. Our vehicle was totaled- with most of the damage being done to the passengerÂs side. My upper right side was beginning to ache, so I was taken to the hospital and given X Rays and a CT Scan. The X rays noted that I had reversal of normal cervical lordosis, although nothing showed on the CT scan. I was referred to Dr. T___ (an orthopedist) at OSMC and participated in regular physical therapy for 3 months. When I showed few signs of improvement, I was referred to Dr. S_____,(a physiatristt) who went on to treat me for nearly a year and a half. While under her care, I received intense physical therapy 2-3 times a week, as well as countless trigger point injections, spray and stretch, E-stimulation and ultrasound. I was tentatively released from her care, but returned when the pain increased again; a pattern that you will find in my records. In May of 2004, she ordered a cervical MRI, and it came back that I had a bulging disk at C6 as well as mild disk degeneration. At that point, I was referred back to OSMC to Dr. G_____ (a pain management specialist) for an epidural. No changes in my condition were noted.
My diagnoses at that point were facet disease, disk bulges, myofascial pain, cervical strain, reversal of normal cervical lordosis and cervogenic headaches. Eventually, I stopped seeing Dr. S____ when the insurance settlement became an issue and treatment came to a standstill. In April of 2005, I was then referred to Dr D________, who came very highly regarded. He began to make major changes in my treatment, as noted in the records sent by his office. I tried Elavil and Neurontin, had numerous nerve blocks done in the cervical facet joints, and received more trigger point injections, all by Dr. P__ (a pain management specialist) to no avail. Last November, with Dr. D________ on board, I began treating with Dr. P_____ ( a chiropractor) . He put me in an intense physical therapy regimen, including; deep tissue massage, e-stimulation, and acupuncture. After a slight decrease in pain, I experienced a flare up that continued for over a month. Dr. P_____ wanted me to continue under his supervision and start spending far more out of pocket, but because the treatment had again, not improved my symptoms, I left his care. Early in 2006, I had a new MRI done on my cervical and thoracic spine. The disk degeneration had increased to moderate, and there were disk bulges at both C6 and C7. There were only mild degenerative changes in my thoracic spine. At that point, I underwent an EMG which showed I had damage to the Long Thoracic Nerve on the right side, consistent with certain pain symptoms I had experienced. I was also sent to see neurosurgeon Dr. C______, who prescribed a selective nerve root block at C7, followed possibly by a myelogram. In July of 2006, after much thought and consideration (as well as 2 more sets of nerve blocks) I went back to Dr. P__ for a 4 level cervical facet rhizotomy. The improvement was minimal at best.
At present, I am taking 60 mg of Kadian ( time release morphine), 12 mg of Zanaflex, 15 mg of Valium, 150 mg of Lyrica and up to 30 mg of hydrocodone every day. That is an incredible amount of medicine for anyone, much less a woman in her prime.
I am about to turn 28 at the end of the month. I am still a relatively young woman. The last 3 and a half years have been anything but easy. I have done everything my doctors have told me to do, including ending my employment, to try and allow my body to heal. The pain I feel is very specific and mostly right sided. I battle headaches that start in the occipital area, my neck has a very limited range of motion, my scalene muscles are often very tight and extremely tender, my serratus muscles are a constant source of pain and irritation, my scapular area is often knotted and sore, my trapezius muscles often flare up and I have a searing or burning sensation that runs down my upper mid back. Flare ups often cause my right arm to hurt, down to my ring and pinkie finger. My life has completely changed. I can no longer go anywhere without first considering how it will affect my body. My activity level is less than half of what it used to be; before the accident I was training to run a half marathon and lived a full life. Now, the most simple task can cause a one or two week flare up. I am limited even in my household activities; I can't sweep, mop, vacuum, rake, or do any sort of pushing/pulling motion without ending up in extreme pain. Sometimes something as simple as reaching for an object will cause a flare up. At 28, I feel more like I'm 58.
I understand that as an insurance company, Cigna has a bottom line. I am a registered life and health insurance agent myself, and I know what the goals of our business are. However, when I look at my case, and the thousands of dollars I've had in claims over just the last year, it seems to me that the most efficient way to handle a case like this is to get specialty care. Say that I continue my current treatment for even the next 5 years. If I don't get any better, Cigna is out tens of thousands of dollars- and that's
just on doctor visits and prescription costs. (Without insurance each Kadian prescription would cost me over $200, for an example). What if we extend that to over the next 20 years? I would be an incredibly expensive client. A primary example of adverse selection, and the client you don't want to have. But, what if someone decides that I warrant at least a visit to a center such as the Cleveland Clinic? What if they come up with a treatment plan that hasn't been tried? What if they can offer answers that my current physicians can admittedly, not provide? If my doctor felt he still had options, we would be exploring them right now. Considering he is one of the most respected physicians in the area, it resonates when he tells me he believes I need someone with more expertise. Dr D________ has already expressed to me that if a new specialist comes up with treatment plans, he will administer whatever he can from his side.
There has been some mention of sending me back to Dr P__ or to Dr S_____. While I have the utmost respect for those physicians, they were unable to help me before. It seems counterproductive to send me back to them, if they were unable to help me get my pain down to an acceptable level in the past. I would assume that Cigna wants the best care possible for it's clients. I am simply asking for that chance. I refuse to believe or give in to the notion that I am going to be in pain for the rest of my life. But I need someone else to help win this battle. So, I am asking you, the physicians of Cigna, to truly examine my case and save both of us battles in the future. I trust that you will review my records thoroughly, in order to come to a mutually beneficial desicion.
Sincerely,
Alli A.
