Dear United Health,
I hope this message finds you well. My name is Jessica Turner, and I am the mother of a precious 4-month-old baby boy, Ethan, who relies on a specialized formula called Elecare to thrive. This isn’t a choice we’ve made for any trivial reasons; it is a necessity for his survival. Ethan suffers from a severe cow’s milk protein allergy, which makes the formula absolutely essential.
Ethan was born prematurely, at 37 weeks, due to a complication I experienced during pregnancy known as preeclampsia. The labor was medically induced. Before you suggest the usual “breast is best” narrative, let me clarify: Ethan had significant challenges with latching, which were attributed to what specialists termed a “poor latch, weak suck, exacerbated by bilateral buccal ties.” Feeding him was a daunting task, even with two other children at home. I committed myself to providing him with breast milk and began exclusively pumping.
Despite my efforts to eliminate dairy from my diet, my milk caused him severe discomfort. For the first four weeks of his life, he cried incessantly, suffering from gut-wrenching pain. His stools were not normal; they were often loose, watery, and sometimes even bloody. At that point, breastfeeding was not an option for us.
After many trials, we were referred to a gastroenterologist who confirmed our worst fears: Ethan had a severe case of CMPA (cow’s milk protein allergy). The spectrum of CMPA symptoms can vary widely, ranging from mild digestive discomfort to severe reactions, like those we were witnessing in Ethan. The latter included constant pain, diarrhea, and eczema, making it clear that he could not tolerate even the smallest amount of cow’s milk protein.
Our GI specialist promptly prescribed Elecare and antispasmodic Levsin drops, also noting that Ethan was suffering from significant acid reflux on top of his allergy. A friend aptly described it: “It’s not a problem until you see your child endure it.” Witnessing Ethan’s struggles was heart-wrenching.
Next, I reached out to our insurance provider to discuss coverage for Elecare, which is priced at an astounding $45 for just a 14.1 oz can. This amount only lasts him about 2 to 3 days as he consumes 4 oz every three hours. I can’t help but compare it to regular infant formulas, like Enfamil, which cost around $12-14 for the same size and are available in bulk for better pricing.
To my dismay, I learned that while many specialized formulas and medical foods were covered under our plan, Elecare was not one of them. This left me utterly bewildered. How is it possible that I am expected to shoulder a $450 monthly expense for a formula that is essential for my son’s survival, while alternative products like Glucerna are readily covered?
Our gastroenterologist went above and beyond, providing samples and coupons while also vowing to advocate on our behalf. We diligently completed every form Cigna requested, including prescriptions for caloric intake and a detailed pre-authorization letter. She even submitted a letter of medical necessity along with Ethan’s complete medical history. Yet, we received a resounding denial.
The reason? Elecare is only covered for conditions classified as inborn errors of metabolism, such as PKU or Galactosemia. Sadly, a cow’s milk protein allergy doesn’t fit into their predefined categories. While I would never encourage anyone to commit fraud, it is hard to suppress my anger at this situation.
Ethan needs this formula to survive his first year; he cannot metabolize any alternative. Without it, the prognosis is dire: failure to thrive and severe dehydration. I acknowledge that CMPA may not be as severe as other conditions, but that does not diminish the urgent need for support.
In Texas, there is a mandate that requires insurance companies to cover baby formula. Given that we contribute over $1200 monthly towards our family plan, it is only logical that you would cover a medical food essential for my son’s health and well-being.
I wonder, would you prefer to deal with the costs of hospitalization for failure to thrive and dehydration instead of providing support upfront? It is disheartening that parents must navigate such bureaucratic hurdles during one of the most challenging times in their lives.
Living in a small community, I am aware of numerous babies who have been prescribed Elecare. To our lawmakers, I urge you to reconsider current legislation. It should be mandatory for insurance providers to assist families like mine, rather than create additional stress.
Sincerely,
A concerned parent of a child with a food allergy.
In Summary
This heartfelt letter outlines the struggles faced by a mother advocating for her child’s medical needs against an unyielding insurance policy. The denial of coverage for essential formula highlights systemic issues within healthcare that must be addressed to ensure families receive the support they desperately need.
Keyphrase: Insurance Claim Denial for Medical Formula
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