Member Impact Stories from THP
This Boot is Made for Walking by Todd Ullom
I received a request to reach out to a member who has a diabetic foot ulcer and is needing a therapeutic walking boot. Upon my first conversation with him, he was very upset, angered, and frustrated. Our conversation was inadvertently dropped due to his phone service, which did not help his frustration level. He voiced that he is upset due to waiting on approval of a boot. He has to continue to be seen at a provider office for a non-weight bearing Una boot to be placed and he is then continually changed for the office examination to have the boot reapplied. I researched his complaint and noted the weight bearing Una boot had been denied for medical necessity. I contacted him the next day explaining appeal process; he gave verbal understanding of the process and stated he would like help pursuing the appeal. He was a little calmer but still had the agitation in his voice. I found that the original referral request was processed through THP and later I found out the CPT code was transposed, complicating the review process. It was then submitted through Evicore, THP’s contracted DME reviewer, who denied it.
At this point, I contacted the requesting provider’s office to clarify the status of the appeal or to see if they were willing or able to do a peer-to-peer review. The office staff informed me that the case was not subject to peer to peer and that the provider level appeal was denied. I next contacted my manager to see if there was a way to assist this member in getting the much-needed weight bearing boot or to bring the referral back to us for reconsideration. She suggested I contact the director of UM with a summary of the case. I reached out to the director and the next day she informed me that additional clinicals were needed. I immediately contacted the providers office and requested clinical notes supporting use of a weight bearing boot to be faxed to me. I received them within a few hours after the request and forwarded them to the director who facilitated getting them to Evicore to reopen the case. I contacted the member to let him know I was trying to help him to the best of my ability and that I would notify him of any updates either way. He was most appreciative, thanked me and asked me to update him as soon as I had a response. After a few days, I checked the Evicore portal and noted they had received the new supportive clinical information and reconsidered their decision. The member was approved for the boot. I phoned him to share the approval and he had informed me his provider had just notified him of the good news. The member sounded tearful but most thankful. He verbally thanked me several times for assisting him and not giving up. I let him know that that’s what we are here to do, advocate for our members and streamline the process to get them what they need. He thanked me again and I encouraged him to call me for assistance any time.
Unwanted Side Effects Hindering Treatment by Michelle Tracy
I started following a member in 2018 related to needs associated with her multiple sclerosis. At that time I started case managing her, she was on no MS medications and had no visits scheduled with neurology. She had taken Copaxone for her MS in the past. Many of her medications were not filled monthly. She was very hesitant to engage in case management when I first contacted her, and her answering the phone was hit or miss. With time and attention, I was able to gain her trust and she confided that she stopped the Copaxone because the side effects were worse for her than the MS. She was having numbness of her feet, legs, and hands, and was having blurry vision, pain all over, chronic fatigue, and headaches. I educated her about the condition MS and the progressive and relapsing nature of exacerbations. I shared information on MS medications and the importance of working closely with a neurologist and getting routine MRIs to monitor the disease. I explained MS triggers, pacing herself to conserve her energy and safety to prevent falls. With support, she did call to make a neurology appointment and the member actually started calling me to assist with understanding her care.
With no treatment for so long, she now needed a wheelchair and incontinence supplies. I worked with her PCP’s office to get the DME supplies she needed. She went to a neurology appt and had a MRI but I was concerned at this point that she was still not on any medication. Around this time, she ended up hospitalized for a MS exacerbation and had iv steroids. Her neurologist then ordered Avonex. There were multiple issues getting this drug filled. The prior authorization was not being completed correctly with one office blaming the other. I worked with both offices and was finally able to speak to CVS specialty pharmacy. I coordinated care between the pharmacy and neurology office. I also contacted neurology and made arrangements for home health physical therapy for the member due to an increase in falls with her recent exacerbation. The member finally started the Avonex for her MS after many delays. She also started Baclofen. She thought the Avonex was helping but she then started having side effects of itching and blisters. Her neurologist next ordered Plegrity, which was denied for medical necessity. So now the member was on no MS medication once again. At this point, I worked with one of the THP pharmacists to figure out the step therapy required for her MS meds. Plegrity was not going to be covered, so I again called the neurology office several times and gave them the pharmacy recommended steps to get to different meds, what needed to be tried before moving to another med based on our formulary.
The member was becoming very upset with the neurology office. She expressed feeling fed up. She felt they did not call her back and did not update her; she was tired of the delays. She asked about changing to a different neurologist and I provided her with a list of participating neurologists in her area. She started back on Copaxone and a boost dose of steroids. She again had side effects from the Copaxone. She was able at this point to make an appointment at WVU with a different neurologist. She was very pleased with her first visit with her new neurologist. She was started on a new med, Rituxan. She stated she could feel a difference in her legs, that they were not as heavy. Her numbness would come and go but it was not constant. Her vision was better; she only had blurred vision off and on in one eye. Her MRI became stable. She started Ampyra and Provigil (which was not covered but, she was able to use Good RX for this). She now continues on Rituxan without side effects. She was provided information for Personal Care Assistance and Modivcare information for mileage reimbursement to help support her visits at WVU. She had me speak to her daughter, who stated her thanks for everything I had done for her mom, helping her when no one else would. Member is now using a cane to ambulate and her following routinely with her new neurology team. Her brain scans are remaining stable.
I recently closed this member’s case, she had all DME needed including a walker, shower chair, cane, and wheelchair. She fills all her medications monthly and no longer has unwanted side effects. She goes to all follow up appointments. She has the PCA and Modivcare information and is self-managing. She thanked me for always calling to check on her, for educating her, helping her get back to a neurologist and back on medication. She thanked me for caring and for all the encouragement.
Amazing Progress by Sheri Meyer
I recently received lab results on a member, that made my day. I first opened the case on him Dec 2019 for diabetes management. He has multiple health issues which include type two diabetes, A fib (with a pacemaker), CHF, chronic kidney disease, and a history of lymphoma in remission. He has been confined to his electric wheelchair and had chronic pressure ulcers to his heels. He is morbidly obese at one point weighing as much as 414#.
His main concern when we first began talking was to get a new “scooter” as his was constantly breaking down. My challenge was to get him to focus on his health. Over the years, while I listened to his concerns and taught him to be proactive and communicate with his providers to get his needs met, I offered education repeatedly on his diabetes trying to stress to him that lowering his blood sugar and A1c would help him to improve his other issues.
I have acted as his liaison calling his DME provider and getting his chair repaired when both motors did go out and the repairs were denied. We did get the denial overturned. I have called the surgeon for him to get appointments rescheduled when Modivcare cancelled his ride and the member was afraid they would think he was non-compliant. We got the rides rescheduled and he kept the appointments. I arranged ambulette transportation for him for a heart cath when he was going to take the city bus and spend the night in the lobby in order to be there at 6 AM.
He is currently struggling with severe lymphedema in both of his legs. He has another ulcer to his right heel which became septic, and he was admitted for that and acute CHF which was a first for that diagnosis. He requires a new wheelchair that will allow him to tilt and elevate his legs. It is too soon for him to get a new chair but his DME provider, his doctor and I are working to try and get it considering how his condition has dramatically changed.
Finally, after all of this, he has begun to trust and listen. His A1c in January was 12. It had risen to that level in April 2021, and he had started on insulin, but his blood sugars were not dropping. He began to be frightened. I was frank with him about what the elevated blood sugars were doing to his body and how important it was to lower them. I reviewed his diet with him (again) which consisted of white bread bologna sandwiches (4 at a sitting) and sugared Kool-Aid. It took multiple repetitions and explanations, but he soon began bragging that he eats nothing but chicken and frozen vegetables now and drinks more water. I have taught him how to shop better at the grocery store, avoiding processed foods and how to ask for lower sodium baked meats at the deli. He has lost about 30# weighing in at 385#. His A1c on May 14 has come down to 6.4! He has a long way to go but this progress lightened my heart. I am so proud of him.