Another denial from Medicaid

I got my decision back today from my state hearing from medicaid, my denial was upheld. I have the option to request an adminstrative hearing but I am going to pass on it since I can't submit any new information, since I was wrongly informed about the info I needed to submit in the first place. I am going to resubmit a whole new claim. Cleveland Clinic informed me it should take 2-3 weeks to get an approval or another denial, the first time I applied it took two weeks for a denial. Once I resumbit all new info, showing cpap compliance and a letter from my sleep specialist stating that cpap treatment has failed for my severe OSA and they deny me again I will contact an attorney. On Medicaid's regulation list it does state sleep apnea is not enough to override the medical nessecity rule unless severe sleep apnea is documented, oxygen saturation is less than 80%, which mine is 85%, compliance is shown and cpap has failed, which it has. This should deem me eligible but knowing Medicaid I will have to go through stress and aggravation. This whole situation is depressing.

I am so sorry for you. That has to be so hard. I wish you so much luck in the next steps you take *Tina*

You are going about it perfectly! Don't give up and keep after them with all your information! Keep submitting! Good luck to you...

Thanks for your responses. I was wondering Debbie, did you get your approval after your 1st appeal or administrative appeal the seond time? I was also wondering did you have each doctor foward the info to medicaid or did you they foward it to the surgeon *****quested the surgery, then they submitted. Thanks, Andrea.

Actually my approval came after 6 denials. had requested an administrative appeal but all that was was someone else looking over the first appeal and they upheld the decision..It was 9 months after my first denial that the approval came through.. and most of that time was the wait that Medicaid puts you through to wait for their answers and to wait for them to review your papers you resubmit... I made the mistake of sending them the things they requested and that took time because they had to return them to me and have them submitted by my doctor...so to answer that question it's best to have everything submitted by your surgeon's office...See if they have a Medicaid contact so that all your paperwork goes to the same person everytime...I think that's what eventually helped me also is my surgeon's office talked to the same person everytime she submitted something and it got down to her asking what more do we have to do to get this person approved.

Thanks for your response Debbie, I really appreciate it. This whole situation is such a pain. Today I called my famiy doctor to get some documentation and the office manager there gives me such an attitude like I'm a big pain in the rear. I can't wait until this nightmare is over. When I spoke to the hearing Supervisor from the Canton office she told me that if I had an open appeal I can fax the information straight to Columbus myself. I think the people in Columbus are just straight out mean. I am not going to chance anything so I will let Cleveland Clinic sumbit everything.

That is the best way to do it. That is where they got me when I sent the xrays, they requested I send them then sent them back stating they needed them sent by the surgeon... I know how you feel about calling the doctor's office for everything. At first i felt so bad doing it because everyone gave me such an attitude and it was a pain to them for me to request this stuff...Then I started to get my own attitude that this was MY LIFE and my only option in saving My life and if I didn't call them (even to check on the status) that it would get pushed back and forgotten...Which a few times it did. So it's great you are on top of everything this early on.....I hated the medical person that was on the phone from Columbus during my appeal!!!! He was very mean... He questioned everything and was saying that even though I couldn't walk it was not life threatening and therefore I had ne medical necessity for the surgery....It was a nightmare and I still can't believe it's overwith now..

Hi Debbie.You were saying you were denied 6 times did you go through hearings or did you keep on starting over.

The first was a denial then I had an appeal hearing..denial.. then an administrative appeal hearing...denied...Then after that there were three other denial letters from Medicaid as my request for surgery was submitted again and then when they requested other information and xrays, I would get another denial letter...