Hi All!!

We just got off the phone with the Administrative Law Judge because we appealed the HMO's decision not to pay for Alan's custom molded Orthotics.

FYI, Alan has the shoes and orthotics. His foot company said they were pre-authorized by his HMO that they would pay.

Don't know if you all know this but medicare guidelines say that they only have to pay for shoes and orthotics in two cases.

1. If the person is a diabetic
2. If the orthotic is part of a brace.

Well, Alan has severe severe neuropathy but HE'S NOT A DIABETIC.

But.....you might be asking, "why are they appealing if they know Alan's not a diabetic"?

THEY PAID FOR CUSTOM MOLDED SHOES AND CUSTOM MOLDED ORTHOTICS IN 2008 and THEY PAID FO CUSTOM MOLDED SHOES IN 2009.

They REFUSED to pay for the Orthotics. Orthotics go INSIDE of the shoes, right?

So when the denials kept coming, we appealed and we were turned down. I say WE, because I was a witness as to his story. And they wanted my testimony.

We just got off the phone. This was a hearing with the Administrative Law Judge, Alan, myself, and 4 reps from the HMO. There was a doctor, a nurse, and two Administrative reps.

We all got sworn in. Alan gave his side first, and he called me as a witness. Of course I explained how, because of his neuropathy, BEFORE he got the shoes, he would walk on the floor, step on things, got an infection in his ulcer, had to have procedures, etc. etc. etc. I was very respectful and stuck to the facts. I also asked the Judge to view the letter from Alan's doctor attesting to the fact as to WHY Alan needs new orthotics every year. Because the judge asked "If he had the orthotics from the previous year, why does he need new ones"

When he read the medical necessity letter he said "Oh, I see, I understand".

Alan had previously told his story about his battle with neuropathy, the pain, the so called meds that did not work in his case, and how he got the foot ulcer (due to his severe numbness while he was on a treadmill during cardiac rehab).

The judge listened to us politely and then went to the other side. Their WHOLE ARGUMENT was that Medicare only covers payment of shoes and orthotics if one is a diabetic and if one needs an orthotic that is attached to a brace. They admitted "We know and fully understand that (Alan) has severe neuropathy but blame it on the people who wrote the manual, etc. etc., we need to follow their guidelines"

The judge then asked them the following question:

"If (Alan), has the same condition, with the same symptoms, then how come you only cover diabetics?" Her answer was "It's in the guidelines, we have to follow the guidelines" Then they went on and on about how they NEVER RECEIVED ANY CLAIM from the Foot Company that provided Alan with the custom molded shoes and the custom molded orthotics. They went on and on about "if we did receive a claim, it would have been recorded, and we have no such records of ever being asked to authorize any orthotics".

When he finished questioning them "they all said the same thing, by the way, they acknowledge that Alan has severe neuropathy but they can't pay because it's not in the guidelines".

Then I politely said: "Your Honor, may I ask them a question?" He said "sure, go ahead". I said:

"If you please, please note, in the evidence that we provided, that you DID PAY FOR BOTH CUSTOM MOLDED SHOES AND CUSTOM MOLDED ORTHOTICS, IN BOTH 2008 AND YOU PAID FOR CUSTOM MOLDED SHOES IN 2009"

Their response: You're gonna love this"

"We have no idea why we paid for these in 2008 and 2009, it was a mistake on our part, we don't know why we did this. Perhaps the foot company called us and asked a general question, and someone on our end assumed something, BUT WE HAVE NO RECORD OF THIS. And there was rustling of papers and they were trying to explain why they paid in the past but they stuck to their guidelines story.

So when this was done, I got a chance to make a statement. "Alan's statement was that it was against the Constitution, and they are discriminating against a person WHO IS NOT A DIABETIC. (Don't know how that went with the Judge, but time will tell).

Me? I simply said "Your Honor, I do not know if procedurally you have to only follow the medicare guidelines, and I have listened to what the others have testified, but my only reply is this: "My husband can't walk anywhere without custom molded shoes and orthotics, and they paid for the shoes for two years, and they paid for the orthotics LAST YEAR, and YOU CAN'T WEAR SHOES WITHOUT THE ORTHOTICS, BECAUSE THE ORTHOTICS GO INSIDE THE SHOES". He had asked what kind of orthotics and how they fit into the shoe, and what exactly did they do for his foot". I answered all the questions (Alan prefers that I do this, he didn't want to). The judge was fine with that.

So I summed it up with the following statement:

"Your Honor, I don't know if it is in your jurisdiction or power, but I ask that a compassionate exemption be made in my husband's case. Because they originally paid for the shoes in 2009, it was their admission that THEY DON'T KNOW WHY THEY PAID FOR THE SHOES IN 2009"

He said "I understand everything you have explained" Then he went on to say he will review the case and we should have a decision in about 2 to 3 weeks.

So here's my question to anyone who has been through this before with ALJ's.

Can they over-rule Medicare guidelines? Because if they CAN'T, then all this was for nothing.

I told Alan. "Maybe he will decide that because you got the foot ulcer in cardiac rehab and MAYBE THAT MIGHT SWAY HIS RULING IN YOUR FAVOR."

Anyone ever had this happen to them, and what was the ruling?

Thanks, Melody
So again, Alan HAS the shoes with the orthotics. His HMO only paid for Shoes, but refuse to pay for othotics.