Well, here's a really interesting turn of events. As you know Alan's PN calls for his wearing custom moded shoes with custom molded inserts. His HMO paid for these two things in 2008.

So in June of 2009, he was fitted for both, and he got both. The company that did it THOUGHT that the insurance company would pay so they went ahead and fitted him and gave him the shoes and custom inserts.

Then they informed us that the insurance company would not pay for the inserts, BUT THEY PAID FOR THE SHOES. Now how on earth can an insurance company pay for custom molded shoes but not custom molded inserts. He obviously needs the inserts to go inside the shoes.

We did the medical necessity thing, we appealed, and today we got the letter from Maximus saying that they are siding with his HMO because ALAN IS NOT A DIABETIC and only DIABETICS (in certain circumstances), can get a show if it's attached to a brace. THEN WHY DID HIS HMO PAY FOR SHOES AND ORTHOTICS IN 2008?

Alan will be requesting a hearing in front of an ALJ.

Oh, just to inform you guys, when this all began and we found out that they would not pay for the custom inserts, I phoned his HMO. I told them, "you paid for the shoes, but not the inserts"?

The reply was: 'We did?? We paid for the shoes??? Oh my, we shouldn't have".

Have any of you (and I bet ou have), ever gone through this, and what happened?

Any comments are VERY welcome. We're talking over $500 here so we need some options. When Alan gets in front of the Maximus ALJ, and says "My HMO paid for the shoes, but they won't pay for the inserts", well, I know Alan, he's not about to go quietly. He's really upset.

thanks guys.

Mel

Have them resubmit the bill with a ICD 9 code that is applicable. Because it is inflammatory, they probably think it is going to get better and they don't want to pay for the shoes. It may be better to code it as polyneuropathy, period. Don't pay anything until they fight this thru, however, do keep an eye on late fees from the provider.

THEY PAID FOR THE SHOES. It's the INSERTS they don't want to pay for. Can't change codes on that. The inserts have a specific code.

Guess what I did?. I went online and downloaded all the diagnostic codes. I have the codes for the shoes and the codes for the custom molded inserts.

We'll bring all this paperwork to the hearing and when the HMO says why they are NOT required to pay for the custom inserts, Alan will say "well, you weren't required to pay FOR THE SHOES BUT YOU DID!!!

Think the judge will say "Good job, I'm on your side" I'm ordering that they pay for the inserts. Think this might happen?

lol
melody

It seems odd that they paid for the shoes and not the orthotics. When they submit the bill for the orthotics, what disease code did they use?

Shoes Code is L3230 (they paid for this).

Orthotics Code is L3030 (they did not pay for this).

In the diagnostic code (13 pages) that I printed out, they codes match.

So shoes were paid for (Code L3230), but Inserts were not.
Mel

Well, some numb skull likely made a mistake. I am sure you will win....knowing you, lol.

--as you indicated in your exchange with the insurance person, that, according to whatever new guidelines/regulations they set up--and a lot of insurance companies have been raising premiums, cutting back benefits, etc., in anticipation of health care refrom bills eventually getting through Congress and putting at least a few more constraints, such as no more denials for pre-exiting conditions, on them--they really didn't mean to pay for the shoes, either, and somebody goofed. (And they'll probably use that as a defense at the hearing--I wouldn't put it past them to claim that you should reimburse them for that mistake, either!)

I suspect that the outcome of this may depend very much on what judge/arbitrator you get--and what mood s/he comes into work with that day. Of course, those kinds of things shouldn't be factors at all.

Make sure you go in with all your documentation--not only the previous insurance reimbursement history, but also Alan's past diagnoses of autoimmune neuropathic processes (after all, he got IVIg) documented by the doctors, and argue politely but firmly. You can ask if they want new statements from the doctors that this is an ongoing situation and is not going to magically disappear one day.

Just another reason to keed on fighting for true health care reform (sigh).

.......they really didn't mean to pay for the shoes, either, and somebody goofed. (And they'll probably use that as a defense at the hearing--I wouldn't put it past them to claim that you should reimburse them for that mistake, either!)........

That was my first thought Glenn.

Mel,
I've heard of this before, and found that the doctor that Rx'd the shoes & inserts - should submit a medical necessity form, stating that s/he feels you must have them both and are medically necessary for your health and welfare.
If you have Rx coverage and meds that are necessary are covered, there is no reasonb to negate a doctor's prescription for a necessary aid.
That may help, I'm not sure.

Melody, Just curious as to what his policy says now as to what it covers. Perhaps things covered in 2008 are not covered now. Lots of times insurance companies only cover shoes, orthotics, etc. for someone who is diabetic and not for others who could also benefit from it. Thanks.

Bob:

The medical necessity letter covered BOTH INSERTS AND SHOES, and the doctor went into specific detail about the inserts writing:

"The orthotic is a platazole form with dispersion around the 1st met head (R), and prevents subsequent breakdown. Without this orthotic and molded shoes, Mr. L will certainly suffer severe keratotic breakdown leading to significant ulceration formation which presents with difficulty in healing. It is important to note that Mr. L suffers from near complete neuropathy of his feet".

AND HE WROTE A LOT MORE.

And as far as bringing all this medical stuff about his IVIG, well, what if they decide to pull the plug on that? I don't trust insurance companies.

This is what Maximus wrote in the denial letter that we got yesterday:

"OUR DECISION"
Our decision is that (name of HMO) does not have to pay for the custom made orthotics you purchased on 6/25/09.

Our records indicate that you suffer from peripheral neuropathy and foot ulcers. Although you state that you are not a diabetic, these custom made foot orthotics are medically necessary in order for you to walk. You would like (name of HMO) to pay for the custom made foot orthotics. (name of HMO) denied your request, stating that foot orthotics are not covered for your condition. Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. (Name of HMO) follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor (name of HMO) provides coverage of orthotics for your condition. Therefore (name of HMO) does not have to pay for the custom-made foot orthotics you purchased on 6/25/09."


SO THERE YOU HAVE IT.

They acknowledge that it's a medical necessity. They have the letter from his doctor indicating that he MOST CERTAINLY NEEDS the custom molded orthotics and the custom molded shoes. BUT BECAUSE HE'S NOT A DIABETIC and doesn't WEAR A LEG BRACE, he's out of the running.

At least this is my determination of this.

Again, none of you have ever had to deal with this actuality???

Thanks Mel
P.S. One more important question. Since they are using the "you don't have diabetes" defense, I gather that Alan's strategy is to go there and implore them to make an exception? Am I correct.