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Did anyone ever have a problem coming off VSL#3?  My Insurance Company does not cover the probiotic VSL#3.  I am appealing the decision.  I was doing very well with it.  It did help me with not taking antibiotic for months at a time. I am now struggling with constipation.  I do eat a lot of fiber but the bad gas comes along with it.   I am taking over the counter probiotic but it is not helping me and I am back on antibiotics.  I am sure that my appeal will get me back on VSL#3 but in the mean time I am struggling with symptoms.  Has anyone experienced this.  Thanks  Grace

 

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My appeal caused my local Blue Cross plan to develop a fairly liberal policy wrt VSL #3 DS. The key language is:
"VSL#3-DS®, available by prescription only as a medical food, may be considered medically necessary for the dietary management of an ileal pouch and ulcerative colitis.
Non-prescription probiotics are available over-the-counter (OTC) and are not covered."

If you're interested in the whole thing (which could be extremely helpful to an appeal, I think) it's at:
http://notesnet.carefirst.com/...04EE6AE?OpenDocument

Hi, Sabina. The first step is to appeal your insurance company's denial of coverage. This may be a one-step process, with a single apppeal, or you may be able to appeal to a higher authority within the company if your first appeal is denied. These appeals should be based on *medical necessity*. Keep records of every denial and discussion, with dates and who you spoke to. Most appeals are in writing, though. Assuming the insurance company stonewalls you, you can appeal to your state's insurance administration on the basis of medical necessity. I see that you are in New Jersey, so you can get started at: http://www.state.nj.us/dobi/consumer.htm

I composed a detailed letter about my case, and my doctor turned it into a supporting letter on his letterhead. The insurance company policy I linked to earlier in this thread is a superb supporting document, so if you include that your doctor's letter might only need to offer details about your particular case.

Good luck!

Last edited by Scott F

Hi Scott... can you send the same to me... your letter and anything else I need. I was just diagnosed with stage 4 Colon cancer and VSL#3 DS has made me feel somewhat normal again. My doctor wrote a note but didn't phrase it right. He said he would compose another one if he has a copy of what to say!!! Thank you Scott!!!!

Janie

Janie, I sent the text to you in a Private Message on September 8th.  Here it is again. I really want to emphasize that the CareFirst policy (linked to above) should also be given to your provider and submitted with the appeal - it's fantastic.

In Pennsylvania complaints are filed at http://www.insurance.pa.gov/Co...t/Pages/default.aspx

The Pennsylvania Insurance Department has a great FAQ at http://www.insurance.pa.gov/Co...InsuranceAppeals.pdf 

Here is roughly what I wrote for my provider to use, which you'll have to adapt a bit. I suspect the last two paragraphs may be most useful to you. In my case the insurance company gave in after a couple of attempts through my state's Insurance Administration complaint process. Good luck!
-------------------
I am writing to request an expedited appeal (based on medical necessity) of your denial of Claim #xxxxx, following your denial of drug coverage for VSL #3 DS. I am Member # xxx. My group # is xxx. I am also requesting coverage for subsequent and ongoing use of VSL #3 DS.
My health has deteriorated markedly as a result of your refusal (beginning this year) to provide coverage. This claim is for the prescription-only medical food VSL #3 DS, which was denied for drug coverage at the pharmacy.
My J-pouch was created surgically in xxxx with a total colectomy after many years of intractable inflammatory bowel disease. It enabled me to resume an active life after years of severe illness. I developed chronic pouchitis, a common complication, in xxxx and it has persisted since then. Chronic pouchitis is the most common cause of pouch failure.[1] Pouch failure would be a personal disaster for me and an enormous expense for you, entailing a complex surgical procedure and a lengthy, risky recovery. Pouch failure is best prevented, both for good health care, sensible disease management, and prudent fiscal behavior.
VSL #3 DS is a well-studied mainstay for prevention and treatment of pouchitis[2],[3]. It is evidence-based, and uniformly recommended by J-pouch experts in the published literature. No well-studied satisfactory substitutes exist. VSL #3 DS has helped me considerably for about 5 years, albeit at maximal labeled doses, which retail for nearly $700/month. VSL #3 DS is available by prescription only at the recommended double-strength formulation.
I’ve reduced my dose of VSL #3 DS, because the full retail cost is unsustainable for an individual, but my health has suffered from the now-inadequate dose. I am trying desperately to avoid pouch failure. When adequately treated I enjoy a physically active, healthy lifestyle, working full-time and exercising regularly. When inadequately treated I have severe abdominal pain, diarrhea, and, most disabling, fecal incontinence. Please consider this appeal seriously. Adequate doses of VSL #3 DS will enable me to function properly, and will ultimately save you money.

[1] Shen B. Pouchitis: What Every Gastroenterologist Needs to Know. Clinical Gastroenterology and Hepatology. 2013; 11:1538-1549.
[2] Gionchetti P, Rizello F, Morselli C, et al. High dose probiotics for the treatment of active pouchitis. Dis Colon Rectum 2007; 50:2075-2084.
[3] Gionchetti P, Rizello F, Venturi A, et al. Oral bacteriotherapy as maintenance treatment in patients with chronic pouchitis: a double-blind, placebo-controlled trial. Gastroenterology 2000; 119:305-309.

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