[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