[MelodyL]

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

[cyclelops]

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.

[MelodyL]

Originally Posted by cyclelops

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

[cyclelops]

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?

[MelodyL]

Originally Posted by cyclelops

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

[cyclelops]

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