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Blue cross of new york refuses CFS diagnosis and treatment.

Discussion in 'General ME/CFS News' started by wingfield, Jul 16, 2010.

  1. usedtobeperkytina

    usedtobeperkytina Senior Member

    Clay, Alabama

    Now, it seems obvious to me the reason CDC says no objective tests for CFS. They have taken the stand that CFS is a collection of symptoms that are not attributed to another illness or biological abnormality (paraphrasing).

    So, anyone with any biological abnormality is put into a different category, the "unknown neurological condition" of the CDC study, or whatever.

    I do believe that CFS could be accurately diagnosed using the fingerprint method. (not testing for fingerprints) You run a collection of tests: NK Cell function, cytokine level, cortisol level, platelet and fibrin test, homocystene, sex hormones, growth hormones, neurological function testing, MRI, EBV titers, parvo activation test, HHV-6 activation test, etc. You get the idea. And if so many of them are positive, then it is considered the pattern that determines CFS. If we can do a collection of symptoms, why can't we do a collection of tests, put together, tells the diagnosis.

    But, as I stated, CDC has put itself against any biological explanation.

  2. muffin

    muffin Senior Member

    CDC Cover-UP- Yet more evidence that the CDC does NOT want CFIDS to be "real"

    First: Here is proof that my brain is very badly damaged and that I do need others to do the real thinking and writing since I simply can not. This thread was on HEALTH INS. not on disability. I did not even think about that until I saw Tina's comment that I went off topic with the Disability post from the lawyer (Marketing for him, but good info for us on disability).
    Second: Tina pointed out yet more evidence that the CDC refuses to allow any sort of testing to prove that CFIDS exists and that would ensure that the health and disability companies provide for the CFIDS sick. I was not even allowed by my company to apply for LTD by the Nurse MBA. She told me that the company would not support my request for LTD since they thought I was depressed, not sick, given the CFIDS diagnosis. Now, there were at least 15 other people at that time who also had all my symptoms BUT, they were given different diagnoses and hence, got LTD. I did not know enough to ask my doctor to diagnose me with anything else but CFIDS. So, no LTD for me and more stress and demands on a very sick body that simply could not function at all.
    We need to gin up a list of all the ways that the CDC has done damage to CFIDS sick so that we are kept in the group of "lazy, crazy" that allows the health/disability/insurance industry to disregard and not provide for our claims.
    As Tina noted, there are many different tests that we "fail" and show how sick we are and yet the CDC claims they don't exist or are not proof enough that we are sick with a disease or, god forbid, a virus of some sort.
    I also believe that Reeves and others ensured that funding for CFS at CDC was kept low and continued to be dropped so that it remained under all radars in the government. My husband and I both know that as a program manager in the government, you fight to keep your funding and to get more funding - not less as Reeves has done. Reeves made sure that he did not fight for more funding so that by the time he retired the CDC funding for CFS would be gone and he would be safe from any malicious findings. Anyone who works for the government knows you fight for funding - to keep your current levels or to increase them, esp. for things like research. Reeves didn't do that.
    Next, as you all know better than I, Reeves picked the stupidest criteria he could to ensure that the people they used for testing would NOT test as sick. Yes, I would believe they got the list from Publisher's Clearninghouse and called people up and asked them if they were tired. There's your "CFS sick people" - not the real sick with real tests and real disablities so horrible that you can't refute.
    And the list of what Reeves and others at the CDC and NIH have done to keep CFIDS and the Retrovirus(es) they KNEW existed going back to the 1980's goes on and on and on.
    Dear God, even in New Zealand they knew there was a virus involved and this is a small country with a small pop and not a huge scientific budget. However, a few good doctors did know what they wre seeing. What happened in NZ that Retrovirus research, etc got killed off? I would like to know that story as well. HOW did the CDC and UK get to them?

    And my first question of all of this is: HOW and WHO in the insurance industries were able to pull strings to kill off Retrovirus research and any other real research at the CDC, NIH, etc.? WHO??? Once we get that real dirt on the connection between Reeves, Weasel/White/Sharpe and the insurance industry there will be an explosion in the media that makes alll other government cover-ups/scandals look like a friggin picnic. I pray that Hillary Johnson and Amy Marcus at the WSJ and other smart journalists dig deep enough to find out this connection and how they all were able to keep this cover-up going for so long and against so many millions of people. Then I want Reeves, White/Weasel/Sharpe and others (Hillary's PERP WALK LIST) to go to prison for the rest of their lives.

    Sorry about posting stuff on disability when the post was on health. That's how bad my brain is. It seems to be getting worse and worse and the LENS stuff has done even more damage to my badly damaged brain. I hate this disease so much....

    -------------------------------Tina's Post Below------------------------

  3. toddm1960

    toddm1960 Senior Member

    Rochester, New York
    Please remember these are companies that use pregnancy as a pre-existing condition to refuse payments or coverage for cancer patients. Don't be surprised they're using CFS to cut benefits. Tell me again what value insurance companies add to health care?
  4. shiso

    shiso Senior Member

    I agree it would be good to find out more about the Blue Cross situation (in light of all the nuances Anika and others pointed out), and if this is going on with any other health insurance companies.

    Of course, the most blatant situation is if they covered a specific ME/CFS patient before for a specific treatment or treatments from the same doctor, then suddenly denied coverage for the exact same course of treatment because of the diagnosis of CFS. If denial really is due to the CFS diagnosis alone, or a strong objective argument can be made that that is effectively what is going on (e.g., if they suddenly changed their position as to whether certain tests or treatments are now considered "experimental"), it's time to go to the press. A WSJ or NYT article with an interview of Dr. Enlander (who I believe has an office location and pedigree that its writers and readership trusts), if he's willing, would be nice.

    I recall there being a state agency (at least in some states) that oversees abuses by private disability insurance companies that a person can file a complaint with that could lead to a state audit of the insurance company; I wonder if there is a similar state or federal agency people who have been denied could file a similar complaint with with respect to health insurance companies - again, assuming that BC is doing this.
  5. adj


    I began treatment with Dr. Enlander in May 2008. From then until July 2009, Empire Blue Cross paid all claims. From 7/30/09 to 4/22/10 they rejected 19 of 38 claims claiming there were insufficient records to determine medical necessity; all 38 claims are identical, and the dates of rejected claims show no obvious pattern.

    Enlander appealed rejected claims for the earliest two dates and lost the appeal as not medically necessary based on the available literature. He says he spoke to the medical advisor in charge of the rejection, a family practice specialist, and asked what course of treatment would be approved. He says the advisor gave no options. I don't know if Enlander asked him to explain why then subsequent claims for the same treatment were paid. Who knows? Maybe Blue Cross will ask Enlander to refund the paid claims.

    So far, Blue Cross's response hasn't changed: insufficient medical records to determine medical necessity. Enlander's office insists it has forwarded all relevant records multiple times. And why wouldn't they? Thousands of dollars are involved.
  6. xrayspex

    xrayspex Senior Member

    I had WPS a private company in the midwest that used to pay somewhat for things like the above, they got real vigilant about denying stuff on me too that is related to CFS in 2009. I think ins. co.s are preparing for the future already....they let some of us slide in the past but perhaps they see danger of a lot more cfs types trying to get things paid for in the future with xmrv......its going to be a battle of big pharma vs needs of big insurance. I dumped WPS ass and went with local private managed care co., they may not be any better but will at least pay everything on their own docs.
  7. citybug

    citybug Senior Member

    Are they rejecting tests, or regular doctor's visits?
  8. adj


    For the claims Blue Cross has rejected, it rejected everything: visits, injections, oral drug administration, even venipuncture for blood draws (though BC paid Quest for the analyses). I'm particularly surprised about the office visits. The last three rejected claims were for simple monitoring visits, almost a month in between, no treatment billed.

    It's as if Empire Blue Cross is has singled him out. I recently got a 2nd opinion that verified his diagnosis--Blue Cross paid for that other doctor, the blood tests and follow-up visits.
  9. adj



    But, interestingly, Social Security accepts EBV VCA and early antigen tests as diagnostic, and has done since 1999.

    From SSR-99-2p (Policy Interpretation Ruling Titles II and XVI: Evaluating Cases Involving Chronic Fatigue Syndrome):
    "Therefore, the
    following laboratory findings establish the existence of a medically determinable impairment in individuals
    with CFS:[4]
    An elevated antibody titer to Epstein-Barr virus (EBV) capsid antigen equal to or gor early antigen equal to or greater than 1:640; "

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