Regence BlueCross BlueShield of Oregon
Level 2/3 Member Appeals, Mail Stop E9A
PO Box 5726
Portland, OR 97228
Member Name: Cullen Doherty
Group No: 10000509
Member No: 921404329
Reference No: 001024538
Request for: Genetics Diagnostics Testing for 81405, 81406, 81407
Level 3 Member Appeal Board -
I am writing in regards to Regence failing to agree to cover the genetics testing for our son, Cullen, who was diagnosed with a seizure disorder at the age of six months. The neurology team at OHSU and now here in Bend are unable to continue to provide accurate information about Cullen’s health because it is still undetermined whether he is suffering from a rare genetic disorder called Tuberous Sclerosis. Should it be confirmed that he does have TS, Cullen will need to not only have MRI’s every year to check his brain but also ultrasounds and CT Scans to check his heart, kidneys and eyes, as this disease causes benign tumors to grow in major organs. These tests will continue to cost Blue Cross Blue Shield a significant amount of money on a yearly basis. If the genetics test is completed and results come back negative, Dr. Bell, here in Bend, can focus on the brain only and no longer send Cully off for 3-5 tests per year chasing the unknown; thus eliminating the majority of the yearly tests. More tests equal more money spent on healthcare costs. I am positive this is not one of the goals of a medical insurance company. One way for you to do this now is by making the right decision and the appropriate decision by approving of the pre-authorization for the three genetics tests (81405, 81406 and 81407). According to Athena Diagnostics (the only genetics test site that does TS tests), the cost of the three genetics tests is $5,999.00.
Here is what you wrote in your last letter dated May 21, 2013:
According to the governing Regence Medical Policy, genetic testing for indications other than determining risk or establishing a diagnosis for a genetically inherited disease may be considered medically necessary when all of the following criteria are met:
1.Diagnostic results from physical examination and conventional testing are inconclusive, and
2. The Clinical records document how results of genetic testing are necessary to guide treatment decisions, and
3. There is reliable evidence in the peer-reviewed scientific literature that health outcomes are improved as a result of treatment decisions based on molecular genetic test results.
Our case meets ALL the above criteria. In order to continue to KNOW anything about Cullen’s unique situation, we MUST go through with genetics testing because the medical community fails to have any further answers at this point. MRIs can help see inside the brain, but the genetics test results provide Dr. Bell and Dr. Colin Roberts (OHSU) with the insight necessary to treat the disorder in order to improve Cullen’s health, as well as make informed treatment decisions.
Thank you for your time.
Sincerely,
Conan and Amy Doherty
