Can they READ? Another denial!

This is a bit tedious. Is this indicative of the failing scholastic system in the USA? Or is it just for those in higher up Government positions?

Can they actually READ?

In the mail today, I received another denial letter from CalOPTIMA in pertinence to the t:Slim insulin pump I wrote about in my earlier post: “Do Doctors Listen… Really”. I supplied more information about my eyesight, and even included the Contact information to THREE eye-guys! Two are Ophthalmologists, one other is an Optometrist with a background in Retinology. All of them have been ‘inside’ my eyes in some time or another for the past 10 years.

I gave consent to all three of these offices to release the medical records about me and my lousy eyesight to CalOPTIMA and Monarch Healthcare for the purpose of my quest for a t:slim.

So, today, I was actually amazed to receive ANOTHER denial from CalOPTIMA about the t:slim. I was calling, going  to Dr. Grants’ and Boyce’s offices on Thursday and FRDAY, the fifth of October. BUT The letter I got was dated on the fifth of October!! In other words, I don’t think they even tried to contact the Optical guys!! I went about, doing all this and they most likely never even looked at it.

The Medical Director involved, Dr. Himmet Dajee is a cardiovascular and Thoracic surgeon. He advised me in this letter to receive an eye exam from an Ophthalmologist to “Confirm any visual impairment that would warrant a new or different insulin pump”!


I already DID this! If they had, in fact, seen anything I sent and pursued it, they would not be making such a redundant suggestion. Incidentally, I do have an appointment for another general look-see with Dr. Tayani on Monday the 15th of Oct. I can get yet MORE paper on that for the good Doctor Dajee as well!

The fact is that I have had worse vision for reading or close up work from the time of my cataract operation almost 2 years ago. CalOPTIMA paid for that. Don’t they have this in their records? My other eye was eviscerated and I now wear a prosthetic. Do they ave it on record? I hope so, as they also covered that! They also have been covering yearly Ophthalmology for me from the time I was taken in by their company.

I cannot believe for a New York Minute that they do NOT in fact, have this data on hand! I am beginning to believe those in the general public who say ‘They all play games. They’re just trying to discourage you’.

Oh, They may try, but they shall fail!

You best believe I am going to appeal, again, again, again AND again!!

It may be their job to wear me down, but it is my mission to NEVER be worn down. I am a visually impaired person who has rights! The right to a device that is safer to use than the one I have. It was good, when I could see it. But now, it is a hinderence to use daily. I know I have a perfectly valid reason for needing to go to another pump.

My Retina

This is a shot of my messy Retina. Taken at Dr. Grant’s office on August 29 2012, my eye was not dilated. I know my capsule where the IOL is implanted has clouded over a bit. It looks almost like a 1960’s photograph of Mars. This is, Ladies and Gentlemen, my only working eye. I am monocular as well.

Unlike the learned people in the review panel, MY eyesight was caused by being born too early. Overexposure to Oxygen in an incubator. Somehow, I think this is better than the ‘selective’ blindness with which they are apparently afflicted, that alone, being by their own volition, is the worst “Handicap” of all..

The saga continues…..

This morning, Oct 10th, 2012 I got a call from Insurance. They hadn’t received any of the documentation from my eye-guys at all by the time Dr. Dajee reviewed my case. This is most likely why Dr. Dajee made the rather insensitive suggestion that I see an Ophthalmologist!

The rep told me they DID receive the requested info (I’m presuming this week…) and she re-submitted it for review to Dr. Dajee. Seems they have a “Time-Line” for appeals and the slow response of different people etc we missed the train. So, yes, I miffed that other’s responses cost me a favorable decision.  If I had been told of this “Time-Line” I would have been on this from the very start of the appeal.

Thing is, Patients and ‘Lay-People’ are NEVER told. We definitely need more transparency in how the officials handle our cases. It would have been very nice to have been told “We need the info by (Date) for this to go thru”. I never knew that at all.

So, again we wait for another decision. The representatives from both my insurances are on board and I emailed them to tell them what’s going on.


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4 Responses to Can they READ? Another denial!

  1. Kari says:

    Don’t leave the insurance company to pursue information – they WON’T do it. Find the specific info you want them to have and send them that info. Also have one of your eye dr’s (or all of them) write a note of medical necessity outlining specifically what is wrong with your eyesight and how the t:slim SPECIFICALLY is the best choice (have them talk about the full color screen, etc). Don’t leave any room for the insurance company to have to go looking for info – they often won’t take the time! At least, that’s how it went in my experience.

    I had my doctor write up a note of medical necessity outlining why I need the t:slim and outlining in detail my medical history, with relevant dates, etc. That way it was all in one place and the insurance company didn’t need to go searching for documents. Don’t count on them to go back through records to see what they paid for – my insurance didn’t seem to realize I have proliferative diabetic retinopathy despite having paid for my laser treatments and a vitrectomy, until they were told specifically by my doctor!

    • They did in fact get the info we had sent, and I have an Ophthalmologist’s app on Monday. He will help write a letter to them also with me beside him. We’ll get this done!

      It’s crazy, huh? Thinking this is why insurance is so expensive for most folks.

  2. Hello would you mind sharing which blog platform you’re wworking with?
    I’m planning to start my own blog soon but I’m having a
    difficult time making a decision between BlogEngine/Wordpress/B2evolution and Drupal.
    The readon I ask is because your layout seems different then mlst blogs and I’m looking for something completgely unique.

    P.S Sorry for getting off-topic but I had to ask!

    • I’m just using WordPress, I do use my photos and can make them set in places around the page, I also make the print larger than the default, but is just the basic WordPress, on the website. Nothing too fancy. I haven’t Posted in a while here, so until I saw if I would USE this often or not, I keep to the free service.

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