Thursday, January 30, 2020

Keystone First Denial - Fighting Back Part 2

You will recall that I have filed a grievance with Keystone First (Pennsylvania Medicaid) for denying Grace her Precision Xtra Blood Ketone test strips. You can read about Part 1 of this process here.

Keystone First just let me know that we will be proceeding with the First Level Grievance on Thursday, February 6th at 2:15 PM. It will be a phone level grievance and not in person. They will call me, and I will speak to three people from Keystone First:

  • a doctor of their choosing
  • a non-elected member of Keystone First (no, I don't know what that means)
  • an elected member of Keystone First (no, again, I don't know what that means)

I am to present my case why Grace needs Precision Xtra blood ketone test strips. They will listen. They may ask me questions or clarification. Then, they will make a decision to uphold their denial OR to overturn their denial and grant Grace the ketone test strips.

We did this in 2016. All of this. I spoke with A Dr. Gail Taylor on the phone, who was not, I repeat, NOT a pediatric endocrinologist. How do I know that? It was the first question I asked Dr. Taylor. She told me she was in internist and a family doctor. I asked if she treated patients with diabetes. 'Sometimes,' she replied. I was incredulous. I was defending my daughter's use of blood ketone strips to a doctor who had no familiarity with diabetes.


From Beyond Type 1

Defend I did. I came with background information, research and facts. Keystone First had been prescribing blood ketone test strips since 2013 for Grace, with no problem. Now, it was a problem as they changed their formulary. Grace's diabetes and her need for the blood ketone strips did not change.

So, on February 6th at 2:15 PM, I will do it yet again. Defend her need to check her ketones via blood drop as opposed to urine test strips. If you would like to know why she needs them, here is some information from Beyond Type 1 about diabetic ketoacidosis (DKA) that's good to know. Here is some more information about from JDRF.

It seems in denying Grace the blood ketone test strips, Keystone First is violating their very own policies about providing care, treatment, medicines and therapies that are 'medically necessary.' How do they define 'medically necessary?' Here is what they say in the Keystone First 2020 Member Handbook, p. 33:

Let's review, shall we?

Will blood ketone strips prevent an illness or condition?
Yes they will. They will prevent DKA.

Will blood ketone strips reduce the developmental effects of an illness or condition?
Yes they will. They will prevent the development of DKA which can lead to coma, hospitalization and even death.

Will blood ketone strips help Grace to get or keep the ability to perform daily tasks?
Yes they will. If she is able to manage her high blood sugars and know what to do, she can continue on with school and other activities. Not being in DKA means she can continue with her life.

So, Keystone First, let's roll.

1 comment:

Sandie said...

Hate that you have to do this....again! Love how prepared you are! Keystone picked the wrong person to fight with! xxoo