Questions and Answers with Elizabeth Irias, LMFT
The following questions were asked during our recent CME webinar, “Denied Due to Lack of Medical Necessity: Preventing & Responding to Insurance Denials for PANS/PANDAS Treatments”
Is there a repository where we can find these laws by state?
In the handout, laws for the top 10 states are provided, as well as the link to an organization (the NAIC) who connects patients with their state’s watchdog organizations… I think that’s a great place to start, as well as reaching out to your professional association for clarity.
Who would be defining the medical necessity law?
Medical necessity laws and definitions are provided by each state.
Can you cite those studies showing it gets worse the longer they go without treatment please?
In the handout, I’ve provided some of the handiest research relating to PANS treatments for use in appeals. I *believe* Frankovich, Swedo, Murphy et all discuss it in the Clinical Management of PANS resource, but I unfortunately don’t know off the top of my head.
The following questions were answered live. Please watch the webinar for the responses.
- How to construct an argument when the State does provide coverage for IVIG for those on Medicaid. How do we hold commercial/insurers accountable to that which the state provides? Answered at 52:28
- How do the newer PANS Laws passing in more states such as Charlie’s Law impact these denials? Answered 55:40
- How would you combat state law that states that a service is not medically necessary if it is considered experimental or investigational? Answered 57:47