If you have questions about the practices of your managed-care coverage, ask the experts at the state Department of Managed Health Care. They take up issues ranging from difficulties getting an appointment to denial of a doctor's recommended treatment.
I'm a 49-year-old woman with chronic regional pain syndrome, which can cause a limb to feel as cold as ice or hot to the touch. Shoes or clothing can be unbearably painful. In some cases, people become bedridden and lose their jobs.
Not everyone understands that this malady never entirely leaves. The symptoms may disappear, then return a month or six months or two years later. No one knows why.
I was given a series of nerve- block injections followed by a procedure called radio frequency ablation. After receiving this treatment I was pain free for more than a year.
My pain returned about five months ago. For a while, I was able to tolerate it. I am trying to keep working, but the pain medication makes me groggy, so I suffer while I'm at work.
I requested another treatment, but my health plan has denied my request, stating that the procedure failed and that it's an investigational treatment. I'm asking that this denial be reversed.
– Beverly Graham, Citrus Heights
The DMHC referred your request for independent medical review by a panel of physicians. They will determine whether the injection would be more beneficial than any other standard available therapy.
There was some disagreement among the reviewers:
One concluded that the medical literature does not contain enough evidence to validate the use of RFA and that it can be considered investigational or experimental.
However, the other two reviewers agreed that the current practice guidelines support performing RFA for situations like yours. They also concluded that RFA was the best option because other treatments such as physical therapy, casting, and cortisone injections were tried and proved to be ineffective in your case.
Though your plan determined that the RFA had not worked, one reviewer stated that "several months of good pain relief is a success and not a failure."
The independent medical review panel overturned your health plan's denial by a majority opinion.
Even medical professionals can disagree over what is appropriate treatment. If your health plan denies a treatment recommended by your physician, first appeal the decision through your health plan. If that is not successful, you may contact the DMHC and request a second opinion.
To ask a question, go to www.sacbee.com/ask or write Second Opinion; Features Department; The Sacramento Bee, P.O. Box 15779, Sacramento, CA 95852.
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