Presbyterian Healthcare Services

Complaint: [redacted]
I am rejecting this response because: Administrative Grievance Reconsideration Committee Hearing was CANCELLED by Presbyterian Health Plan for reasons previously discussed
Madam M[redacted],
Thank you very much for forwarding
the information I provided in my previous correspondence to the other
departments at Presbyterian Health Plan.
I look forward to their responses and for a favorable resolution
regarding continuous glucose monitoring sensors (CGMs) as a pharmacy benefit
just like glucose test strips listed in Presbyterian's formulary. Neither item fits the definition of "Durable
Medical Equipment (DME)" as provided by New Mexico statute or Federal statute
(definition provided below). An
explanation by Marketing and Pharmacy would be greatly appreciated
(1) "durable
medical equipment" means a medical assistive device or other equipment
that:
(a) can withstand
repeated use;
(b) is primarily
and customarily used to serve a medical purpose and is not useful to an
individual in the absence of an illness, injury or other medical necessity,
including improved functioning of a body part;
(c) is appropriate
for use at home exclusively by the eligible recipient for whom the durable
medical equipment is prescribed; and
(d) is prescribed
by a physician or other person licensed by the state to prescribe durable
medical equipment;
Even though the New Mexico Superintendent
of Insurance has set forth the regulatory process for an "Administrative
Grievance" they will not intervene or enforce the process because of its
administrative nature. With that being
said, after my Administrative Grievance Reconsideration Hearing was cancelled
by Presbyterian on September 17, 2015, I initiated the "Adverse Determination"
process with Charmaine R[redacted] on September 22, via telephone and confirmed
via email on September 23, 2015. I have
yet to receive any information as to status.
Hopefully, we can employ the Presbyterian Health Plan motto "Tougher
Together" and get this resolved
Respectfully,
[redacted]
[To assist us in bringing this matter to a close, the consumer must give a reason why they are rejecting the responseIf the consumer does not provide a reason if he complaint will be closed Administratively Resolved]

Complaint: [redacted]
I am rejecting this response because: the proposed solution provides no remedy or relief to the outstanding question posed in the initial complaint
Dear Madam
M[redacted],
Unfortunately,
you have been misinformed regarding the cancellation of my Administrative
Grievance Reconsideration Hearing Request.
When enlisting health care professionals and company representatives to
provide expert testimony at the scheduled hearing, I requested appropriate time
for each representative to present. I
was told that Presbyterian would not allow that
In lieu of
the fact that Presbyterian has had difficulties identifying the exact medical items
in question and their purpose, I considered it reasonable for your office to
provide appropriate time for testimony since you are dealing with very
important health issues. My request for
appropriate time was refused and subsequently cancelled under the guise that
Presbyterian did not hear from me. I did
not need an Appeal Extension/Advance Notice Waiver Request (see attached).
Therefore,
the first thing to do is to pull the issues out of the bureaucratic blur
produced by your response and answer each.
Please make sure that the clearest question is not weakened by spurious
association with more difficult onesPlease do not allow any relatively
straightforward questions to be disguised by the difficulty of others. Your help in answering will be beneficial to
other members
1)Please
explain why continuous glucose monitoring sensors (CGMs) are considered Durable
Medical Equipment (DME) under all of your benefit plans when
the item does not meet the minimum criteria set forth by the state (NM) or
federal definition of Durable Medical Equipment (DME)? (state definition provided)
(1) "durable
medical equipment" means a medical assistive device or other equipment
that:
(a) can withstand
repeated use;
(b) is primarily
and customarily used to serve a medical purpose and is not useful to an
individual in the absence of an illness, injury or other medical necessity,
including improved functioning of a body part;
(c) is appropriate
for use at home exclusively by the eligible recipient for whom the durable
medical equipment is prescribed; and
(d) is prescribed
by a physician or other person licensed by the state to prescribe durable
medical equipment;
2)Please
explain why I have not received information regarding the status of the "Adverse
Determination Grievance" filed with Charmaine R[redacted] 09/22/
3)Please
explain why Glucose Monitoring Test Strips are listed on the Presbyterian
Formulary and Continuous Glucose Monitoring sensors are not. Comparison of these two(2) items was made by
the Presbyterian EWCM Research Specialist and was provided in previous
correspondence as a reason for denial
4)Does
Presbyterian use a Pharmacy Benefit Management company like [redacted] or now [redacted]?
In closing,
thank you for advising me of my rights with regard to Presbyterian. However, after attempting the other options,
I choose to seek resolution via means provided by the Revdex.com,
at this time
Thank You,
[redacted]-
[To assist us in bringing this matter to a close, the consumer must give a reason why they are rejecting the responseIf the consumer does not provide a reason if he complaint will be closed Administratively Resolved]