Conquering Sjogren’s: Follow us on our journey to change the face of Sjogren’s

Clinical Practice Guidelines for Ocular Management in Sjögren’s

Posted on Wed, Jul 20, 2016

July is Dry Eye Awareness Month! During July, the Sjögren’s Syndrome Foundation works to help educate the public about dry eye symptoms, treatment options, and the possible cause being Sjögren’s. We hope you enjoy our July blogs aimed to promote dry eye education and encourage you to share this post.

The Sjögren’s Syndrome Foundation (SSF) has developed the first-ever U.S. Clinical Practice Guidelines for Ocular Management in Sjögren’s to ensure quality and consistency of care for the assessment and management of patients.

The SSF Clinical Practice Guidelines for Ocular Management in Sjögren’s established that, in a given patient, the clinician must determine whether the dry eye is due to inadequate production of tears, excess evaporation, or a combination of both mechanisms. The success of a treatment option depends upon proper recognition and approach to therapy.

Click here to view the SSF Clinical Practice Guidelines for Ocular Management in Sjögren’s and its recommendations.

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The SSF Sjögren’s Clinical Practice Guidelines initiative is funded fully by the SSF with no corporate or pharmaceutical industry support. The SSF would like to thank our committee chairmen and members of the ocular working group for volunteering their time and expertise to develop these guidelines. We would also like to thank all SSF members and our generous supporters for helping to make the dream of Sjögren’s Clinical Practice Guidelines start to become a reality! 

Click here to view the U.S. Clinical Practice Guidelines  for Ocular Management in Sjögren’s   

Topics: Sicca, Dry Eyes, Sjogren's, Treatment, coping with sjogren's, Punctal Plugs, Clinical Practice Guidelines for Ocular Management, Clinical Practice Guidelines

Sjogren’s Health Insurance Reimbursement 101

Posted on Tue, Aug 11, 2015

The Sjögren’s Syndrome Foundation (SSF) knows that obtaining healthcare and dental reimbursement can be a major challenge. Having Sjögren’s places a high enough burden on patients, and adding the barriers patients face in obtaining health insurance reimbursement increases that burden greatly. These tips below should help you increase your chances of success when requesting reimbursement and appealing denials for a claim. 

Tips for Health Insurance 

SSF_Health_InsuranceKnow your insurance policy and what it covers.
  • Note whether prior authorization is needed for a specific therapy or procedure.
  • Understand co-pays and how much you will be expected to contribute to the cost.
  • Know whether your insurance company requires “step therapy,” which means you must try and fail one therapy before the next level of therapy can be covered. 
Make sure your medical records are accurate.
  • Maintain copies of your medical records. You have the right to receive copies of all of your medical records. Note that you can be charged a copy fee.
Include a Letter of Medical Necessity.
  • A Letter of Medical Necessity is usually written by the physician explaining why a therapy or other treatment is medically necessary. This can be included with an initial claim or included in the appeals process.
  • A Sample Letter of Medical Necessity for dental treatment can be found on the SSF website under “Brochures and Resource Sheets.
Know how your insurance company handles biologics if you are considering one.
  • Insurance companies can exclude a drug from coverage or it might be a “tiered” drug, meaning one that is designated at a certain level for how much the patient must cover.
  • If not covered, or if the patient coverage is too high, request an exemption along with an explanation about why you need the drug from your physician.
Always appeal denials!SSF_Apeal
  • Appeal a denial at every level. Most patients receive at least partial reimbursement upon appealing a negative decision from their insurance company.
  • Involve your doctor in helping you respond to a denial. 
  • Familiarize yourself with your insurance company’s guidelines and deadlines for appeal. This information is usually included in the denial letter.
  • Make sure you have the necessary documentation showing that your case meets the insurance provider’s guidelines and demonstrates medical need.
  • Maintain records of your communication with the insurance company and document every time you speak or hear from a company representative. Record the person’s name, date, time and key messages from the conversation.
  • Understand why you were denied, so you can address the reason(s) directly.
  • If you are communicating with the Customer Service office of the insurance company and are dissatisfied with the response, ask for a Nurse Case Manager or a Supervisor who might be more understanding of your situation.
  • When possible, demonstrate that treatment is more cost-effective than alternatives or non-treatment. 
  • If you are still denied following the final round of appeals, contact the advocacy or patient assistance program for the company that produces the therapy. Most companies have divisions that take applications for financial assistance for their therapies.

This information was first printed in the The Moisture Seeker, SSF's patient newsletter for members, and is one of the SSF Patient Education Sheets. 

Click Here to Receive our Newsletter  by Becoming an SSF Member

Topics: Sjogren's, Tooth Decay, Treatment, Punctal Plugs, Advocacy, Health Insurance Reimbursement

Sjogren’s and Punctal Plugs: Pros and Cons

Posted on Tue, May 01, 2012

Punctal plugs have both pros and cons. The pros are that they are a safe method to retain tears on the ocular surface and have value in relieving symptoms when tear production is borderline or if the duration of applied tear substitutes needs to be prolonged. They are helpful as adjunctive treatment in the management of dry eye disease.

The cons are that when applied in the presence of inflammation that can occur as part of dry eye disease, they may aggravate symptoms by allowing the inflamed tear to have prolonged contact with the surface of the eye. Therefore, my recommendation is to treat the underlying inflammation before placing the plugs. Another con is that they can fall out and need frequent replacement. Rarely, the plug can provoke a localized inflammatory reaction in the tissue of the eyelid and produce a granuloma at the opening of the tear drainage puncta.

On balance, punctal plugs are a useful adjunctive treatment for dry eye disease but should be used in conjunction with other therapies to control inflammation.

By Gary Foulks, MD

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Topics: Dry Eyes, Sjogren's, Treatment, Punctal Plugs

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