What to do!

@bluebonnet242 Your prior hip fracture and your t-scores are all totally in support of high risk of fracture. A prior lumbar or hip fracture is about is complete evidence of high risk. Nothing else should be needed. If it was a -3.8 for total hip is definitely high risk. Definitely appeal. Is this an insurance company or Medicare? Persist and you should get this reversed. Good luck.

Thanks for replying. I have employer insurance through my husband. When appealing is it best to have the doctor appeal for me? What other evidence do you think I should give the insurance company to prove I am high risk?

The denial said in order to appeal to give a statement explaining that you are filing an appeal and a written explanation of why you believe this case should be reconsidered. Please submit all medical records, peer review articles, and comments for consideration that may support your appeal.

It sounds like an osteoporotic fracture to me. And I totally agree with comments by @awfultruth. I'm not familiar with authorization though. There are lots of members here went through the process for sure.

You can use this link to calculate your frax risk yourself. The score could be used (especially if not good) for part of the appeal:
https://frax.shef.ac.uk/FRAX/tool.aspx?country=9
Best of luck!

@bluebonnet242 As I said previously your prior fracture first and your T-Scores second should be ironclad evidence. Done deal. Your insurance company may just have a policy of rejecting requests out of hand using the logic that most people won't appeal further. So it may be that once you appeal they will do the reasonable thing and approve due to a recent prior fracture.
Still I would present all kinds of evidence just to show them "you mean business".

Here's an example of a study showing 7% increase in one year in fracture risk with a prior fracture. 12% in two years. Another study mentioned had 16%. The study says there should be health services to speed emergency action after fragility fractures in order to prevent subsequent fractures.
ttps://www.ncbi.nlm.nih.gov/pmc/articles/PMC6422949/

Be sure to call your prior fracture a fragility fracture.
If you could find a passage in one of the US osteoporosis guidelines about fragility fractures increasing future fractures that would be a good thing to include.

With effort I think you will succeed with this and maybe more easily than you think. I managed with a lot of hard work to get approval from both Medicare and Amgen safety net for Evenity. And I'm a guy and had no prior fragility fractures. You should have a much easier path to the meds you need.

Thank you both for advice!

My doctor had already appealed for me before I gave them any additional information and unfortunately it was denied. I am meeting my doctor next week with the articles both @awfultruth and @mayblin have suggested as well as some other info and to see if the doctor has any other ideas to get this med approved. If not approved, I’m not sure what to do. Maybe the letter just needs to reworded.

@bluebonnet242 I have had some success calling insurance and asking for a supervisor. They can at least give you guidance on what to ask your doctor to write.

With any fracture you should qualify, and with severe scores, even more.

Also have you checked with the companies on financial assistance?

I had an MRI rejected and the insurance sent me a note saying "neck pain" was not enough justification. Turns out my doctor had written a detailed authorization with spinal levels of stenosis, myelopathy, radiculopathy and fractures. The doctor had no idea how that turned into "neck pain."

I urge you to talk to insurance yourself. They can even expedite the authorization. Supervisors can be helpful. Just ask the representative.

How often are the insurance apps rejected?

Your fall over an uneven sidewalk validates my decision not to walk the sidewalks of my lovely little Spring Green village which are less than even. I find it much safer altho much less scenic to talk around & around the utility core in my cottage in rural Wisonsin. The cats thought I had gone mad at first but have now gotten used to it & pretty much ignore me unless it's close to mealtime time!

Can I ask who your insurance company is? Is sharing that information permitted?