How to appeal site of service denial?
Hi all, here's my story/question. I'm on BlueCross BlueShield of Arizona through my employer, but live near Seattle, WA.
My wife is undergoing treatment for lung cancer at Fred Hutchinson Cancer Center. Our dr wanted to switch to a new chemo drug called Enhertu. They put in the authorization request and our insurance denied it because we are at a non-preferred facility. Their preferred facilities are at home, physician office, or stand-alone infusion center. Fred Hutch is considered a hospital, and hospitals are non-preferred for some reason.
We're at the best possible place we could be getting treatment, but such logic doesn't matter with insurance. After some digging I found a document listing site of service requirements for certain medications. It lists out some rules that would allow a non-preferred setting to be approved, and this is where I need help.
We've met 3 of the 4 rules, but the last one is tricky. It says:
Individuals' home is not eligible for home infusion services (such as the home is not withing the serivce area, or the home is deemed unsuitable for care by the home infusion provider) as defined by either:
a. All Preferred site of service are:
– Greater than 15 miles of individual's home in a metropolitan area AND there are no preferred sites of service located closer to the patients' home than the requested non-preferred site of service OR
– Greater than 40 miles of individual's home in a rural area AND there are no preferred sites of service located closer to the patients' home than the requested non-preferred site of service.
We would be in a metro area, so 15 mile radius. I called insurance and talked to someone in CS who sent a list of possible places in our area, but it's more of these places are in network, not these have exactly what you need. So far I haven't been able to find an independent (non-hospital affiliated) infusion center that can help us. It's giving me hope, but I don't know how to document this and mount a thorough appeal that can get approved.
Any help would be greatly appreciated.
submitted by /u/SkinnyFatGuy20
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