Member Receives $20K Reimbursement After Paying Out of Pocket for Denied Medically Necessary Treatment

The Client

Company operating in the construction industry with ~30 enrolled employees

The Challenge

After being diagnosed with a rare, debilitating autoimmune disorder, two dependents needed Intravenous immunoglobulin (IVIG) – a very expensive treatment categorized as experimental. Due to its classification, the member’s insurance carrier denied coverage of their doctor’s authorization for the medically necessary treatment, stating “insufficient evidence for effectiveness” – even though one of the dependents had IVIG in the past and it worked wonders.

The Solution

The Caravus Advocacy team began a lengthy appeals process with the carrier. First, the team tried to get in touch with the carrier’s specialty pharmacy to discuss the denial in further detail, to no avail. Then, they went back and forth with the carrier for months – going as far as requesting a peer-to-peer meeting between the carrier and the dependent’s doctor. During this time, the family decided to move forward with treatment, paying a significant amount out of their own pocket.

For a total of 6 months, our team constantly followed up with the carrier, keeping the family in the loop until all parties finally came to an agreement.

The Outcome

The carrier ended up processing the member’s claims, covering $25,000 of the previously denied services, and the family was reimbursed roughly $20,000 from their provider. While the family still had to pay money out of pocket, the dependents received the treatment they needed and are back to participating in school and sports.