An Update on Horizon Blue Cross Blue Shield of NJ's Shameful Denial

This is an update on the Horizon's recent denial of physical therapy.  To quickly summarize, John had a stroke on Father's Day in 2013, which affected his right side and his speech, but he worked his way back to walking with only slight limp after being given very little physical therapy because I was told Horizon Blue Cross Blue Shield of New Jersey wouldn't cover it any more.

John had another stroke on 10/26/14 which again affected his right side but his leg is much worse this time.  Although John had also been diagnosed with prostate cancer and has been going to daily physical therapy and daily radiation treatments at the same time, he has still made tremendous progress.

The problems started when Horizon started denying John's physical therapy after only a month.  John’s doctor did talk to a doctor at Horizon which got John another week of PT in mid-December.  Then before Christmas, they cancelled PT again which is when we had a first level expedited appeal which denial was upheld, followed by a second level expedited appeal conference call with two doctors and a nurse from Horizon on 12/23/14 which we won but for only two weeks; one retroactive and one through 1/5/15. 

PT was denied again on Monday, 1/5/15, so we had another first level expedited appeal followed by another second level expedited appeal by conference call on 1/7/15 but this time we lost because they said he wasn't making progress which is blatantly untrue, and that PT wasn't medically unnecessary.

That is when I started this blog post and posted it on Facebook asking my 500+ family and friends to share it with their family and friends.  I then posted this information on Horizon's Facebook page.  They sent me a message on FB twenty minutes later asking for me contact information.  I received a call from Horizon and explained the situation and was promised a call back.  

I received a call on Friday, 1/9/15 from an RN who basically repeated what was in the appeal letter, and told me that John wasn’t making progress and PT was medically unnecessary.  I now have to file a third level external expedited appeal and do not have much hope.

Since I shared this blog on Facebook, I have had numerous comments and advice from many of my family and FB friends and I have been taking their advice.  I just sent an email to the Fox Hall of Shame and I'm keeping my fingers crossed.

Thanks so much for everyone's support.

Cathy