Battling insurance

Well after another long fight we finally got my insurance to approve remicade. The down side to this is they will only approve it for every 8 weeks and my doc wants me to have it every 6 weeks. they say there is no medical evidence or clinical studies that prove higher dosing or more frequent dosing is effective in PsA. I on the other hand can tell them that for me it only works for about 5 weeks before I start swelling up like the goodyear blimp and have tremendous pain. I would like to know if anyone knows of studies or any info I could use in my appeal process that more frequent dosing of remicade is helpful. I would really appreciate any help I could get. thanks everyone

No I do not sorry but doesn't it make you crazy on how a person behind a screen knows what is better for you than your own doctor! All I can say is push on and never take the answer no.


Agree on the keep pushing. Your doctor should be able and willing to provide studies to your insurance company to support his/her treatment plan. I had call after call after call and three appeals before my daughter’s treatment got approved. Be relentless.

Best wishes!

Get started first, once you figure out how dosing will effect you, you will have a stronger stance with the insurance company. There is a basis for more frequent dosing and many docs are using it at 6weeks -even at 4weeks. None of the insurance companies would be paying for it, if it weren’t effective. Many docs have 6 week dosing as their standard of care. There is also flexibility with the strength of each dose. So do the best you can with the 8 week dosing and then worry about your appeals once the doc decides there’s no where else to go the with strength of the dose. Also, keep in mind that the longer you are on it, the more it is accumulated in your system, so you might make it 6-7 weeks without needing more frequent dosing; but you just need to get there. MTX tends to help prevent the trough effect and veg things out between doses. Something to talk to your doc about. Your rheum should manage your appeals for you. Usually it just takes one appeal, but do be persistent if you are denied. The squeaky wheel usually gets the grease in these cases.