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Breathing: Not Medically Necessary

Posted Mar 12 2010 10:33am
Apparently, Aetna Insurance has sunk to a new low.
Maybe even the lowest of lows.
It's bad enough that they think my daughter's inability to communicate effectively at her chronological age was not enough.
Now, they want to deny coverage of the nebulizer machine that both of my children needed a few weeks ago.


Let me see if I could get this straight.
Let me see if I could "think" like Aetna Insurance.
OOPS! My fault. My apologies.


My daughter is sick.
She starts with a cough.
She is first diagnosed with an upper respiratory infection.
Which turned into bronchitis.
Which evolved into right upper lobe pneumonia.
Which required THREE rounds of antibiotics to clear.
Which took two doctor's office visits and one Emergency Room visit.
Which required nebulizer treatments WITH MEDICINE IN IT to help open her airway.

Then my son becomes symptomatic.
Just like big sister.
Which starts with a cough.
Which turns into an upper respiratory infection.
Which turned into bronchitis.
Which took TWO rounds of antibiotics to control.
At which point our incredible pediatrician decided to prescribe the exact same bronchodilating medication.
To open his airway.

Somebody, anybody, please explain how idiotic morons have been appointed to be in charge of what is medically necessary and what is not medically necessary.
Shouldn't that be left up to, oh, I don't know....DOCTORS!!!!!

So I go to
I look up the Clinical Policy Bulletin for nebulizers.
And this is what I find*************************************************************************************
*Clinical Policy Bulletin*Nebulizers

Number: 0065


I.Small Volume Nebulizer

The use of a small volume nebulizer and related compressor is considered medically necessary durable medical equipment (DME) for any of the following indications
A.To administer beta-adrenergics (albuterol, isoproterenol, isoetharine, levalbuteral, metaproterenol), anticholinergics (ipratropium), corticosteroids (budesonide), and cromolyn for the management of obstructive pulmonary diseases (chronic bronchitis, emphysema, asthma, etc.);* or
B.To administer dornase alfa** to members with cystic fibrosis; or
C.To administer antibiotics (gentamicin, amikacin, or tobramycin,***) to members with cystic fibrosis or bronchiectasis; or
D.To administer pentamidine to members with HIV, pneumocystosis, or complications of organ transplants; or
E.To administer mucolytics (other than dornase alpha) (acetylcysteine) for persistent thick or tenacious pulmonary secretions; or
F.To administer iloprost via a controlled dose inhalation drug delivery system to members with pulmonary hypertension; or
G.To administer formoterol (Perforomist) or arformoterol (Brovana) for the management of chronic obstructive pulmonary disease when medical necessity criteria in Pharmacy CPB on Long-Acting Beta Agonists are met.
Small volume nebulizers and related compressors are considered experimental and investigational for all other indications.

* For criterion (a) to be met, the physician must have considered use of a metered dose inhaler (MDI) with and without a reservoir or spacer device and decided that, for medical reasons, it was not sufficient for the administration of needed inhalation drugs.
Both of my children were prescribed Levalbuterol, as seen in (A).
And, based on their ages as well as medical history, they meet criterion (a).

See my frustration, folks?
I said it before and I will say it again: MORONS!
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