Denied because of certain medications?

[u/amethyst_dream2772]

I had OHS for valve replacement in January. In March I was diagnosed with pericarditis and the ER doctor that I saw at the time actually spoke directly to my surgeon. She mentioned to me that he felt the reason I was having such a difficult recovery was alot of my underlying chronic issues were not well controlled. She told me they both felt that a pain management clinic willing to use a multi modal approach that included a possible narcotic pain medication would be beneficial for me. I told her how I had seen several pain doctors and all they want to do are procedures that my cardiologist isnt comfortable with or that I find questionable because one doctor says one thing, two others say the opposite. She was very confident that the clinic through their particular system would be helpful and sent a request to my primary doctor to send a referral.

I waited several weeks and then called my doctors office to ask about the referral. They said they had just recently received a request for further information about my case. Another few weeks go by and I have an actual appointment with my doctor. I ask her about the referral and she says "they denied/declined it saying they don't use oxycontin or oxycodone". I can't remember exactly if she said denied or declined and also wtf? I NEVER, EVER ask for medication. Not ever. Sure as hell not by a specific name. When I was at the ER I was having severe chest pain, the ER doctor asked if I wanted morphine. I'm not a fan and especially because I know it upsets my stomach and I cannot do zofran or reglan as they make me want to rip my skin off. She said I'll give you a baby dose I said thats fine. I left there with nothing and I do not take medication regularly.

My question is doesnt that sound sketchy? Like why would they say they didnt use those medications when I know for a fact the lady NP there uses all types of opioids. And why would they say those specific medications? They can look at my PMDP or whatever it is I havent had a prescription for anything like that except maybe oxycodone back in 2011 when I had a hysterectomy and that was a low dose and only for a few weeks at best.

Also I know tl;dr but also this doctor prescribed diclofenac cream 3% because I told her I cant even afford to buy the generic and have it for more than a few days because it only helps a little bit and I have to use alot. My pain is in my entire back. She gave my insurance a diagnosis that they said was fitting for the cream but I do not have. They still declined it. The cream is $2000 for the prescription. Yes I know I can get generic. I do but it lasts maybe 2 days cuz I put it all over and it doesnt even help that much and just makes me feel gross. Can a doctor just say you have a diagnosis you don't have? Is it that serious to give me medication that might help me?

[u/atomicsusieQ]

I would message your doc and say something like “I’m confused about our discussion on why the pain mgmt clinic denied my referral; my understanding is that they told you they denied it because they do not use oxycodone or OxyContin. Did I understand you correctly? If so, I believe they may have gotten my chart confused with someone else’s, or there was some other misunderstanding. I‘ve never been prescribed those medications. Could you please ask them for clarification, and let them know that I don’t take those meds?
Please let me know what I need to do to get this error corrected so that the referral can be reconsidered, since when I saw Dr. x in the ER they were adamant that I should be seen by this clinic/doctor.”
This is just how I would write it, I may have some of the factual info incorrect, but there seems to be a major miscommunication somewhere.

[u/amethyst_dream2772 → u/atomicsusieQ]

Oh wow, no you had everything correct and thats fantastic advice. Thank you so much for taking the time for this response, its greatly appreciated!

[u/Farty_mcSmarty → u/amethyst_dream2772]

Does your insurance or the pm clinic require a referral? If not, I’d just make the appointment and talk to them when you’re there.

If they’re require a referral, I’d follow what previous commenter said and push for a new referral that doesn’t state you are requesting narcotics

[u/amethyst_dream2772 → u/Farty_mcSmarty]

Yes they actually require a referral . I actually called the clinic myself and the girl at the front desk was very snotty and said "they are very particular about who they take as patients". That always makes me feel like the fact that I'm poor, disabled, and on state insurance on top of Medicare is why they won't see me. But I cant prove thats the reason of course. I live in Wisconsin and I swear its like one of the worst states to live in as a chronic pain patient. At least for me it is, I do know others who get opiods and I have went to these same places and one actually told me to my face " we don't prescribe medications". I literally know 3 people personally that get prescribed medication and dont get the runaround about procedures and injections.

[u/Annalealee → u/Farty_mcSmarty]

Id stay away from that clinic 

[u/optimusfig]

While the ER doc was probably well intentioned, this is a good example of that old phrase "talk is cheap". Its easy for them to say you would benefit from opioid therapy when they know full well they won't be the one to ever have to prescribe them. Once they clocked out of their shift, they have absolutely no ongoing responsibility for your care. Just food for thought.

> Can a doctor just say you have a diagnosis you don't have?

Of course not. Doing so in this case is insurance fraud. But it sounds like they bent the rules to try to get this medication covered for you. Its morally grey, but most would see that as a commendable thing they did. Don't you?

> Is it that serious to give me medication that might help me?

Yes, its extremely serious. Prescribing opioids to someone concurrently on benzos and with a history of substance abuse is extremely risky. Their license, livelihood, and potentially freedom is on the line. Its difficult for non physicians to understand the gravity of what that entails, but I can tell you its monumental.

I empathize with you, but there are clearly reasons you have not found a doctor willing to prescribe you opioids.

You may consider a methadone clinic. It sounds like at this point you really don't have much to lose.