[MelodyL]

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.

[echoes long ago]

i dont know the answers to your questions about if the alj can overule medicaid guidelines but i just wanted to say that i think you did a great job and gave it the good fight. You should have directly asked the insurance people about wether they ever received the paperwork from the orthotics place for authorization and reminded them that they were under oath.ha! They are all full of doggy diamonds. Did Alan get another pair of shoes paid for by the insurance company? Its not clear at the end of your post it seems he got another pair of shoes but i might be misinterpreting. I wish you luck and hope he gets the orthotics. This is where our "ADVOCACY" organizations should be involved in the fight.

[MelodyL]

Originally Posted by echoes long ago

i dont know the answers to your questions about if the alj can overule medicaid guidelines but i just wanted to say that i think you did a great job and gave it the good fight. You should have directly asked the insurance people about wether they ever received the paperwork from the orthotics place for authorization and reminded them that they were under oath.ha! They are all full of doggy diamonds. Did Alan get another pair of shoes paid for by the insurance company? Its not clear at the end of your post it seems he got another pair of shoes but i might be misinterpreting. I wish you luck and hope he gets the orthotics. This is where our "ADVOCACY" organizations should be involved in the fight.

Thanks for the nice words.
Yes (read the very last line of my original post.
this is what I said:

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

What this means is that Alan got a new pair of shoes in 2009, and his HMO paid for the shoes, but they refuse to pay for the Orthotics that were fitted to go INSIDE of the shoes.

In 2008, his HMO paid for BOTH shoes and orthotics. But in 2009, they only paid for shoes.

Then they said they never pay for shoes and orthotics unless a person is diabetic or unless the orthotics are fitted with a brace.

That's when I politely interrupted and said ""But oh, you DID INDEED pay for the shoes and orthos in 2008 and you paid for the shoes in 2009" and the Judge then said: "why did you pay for these items?" and the girl said "Well, to tell you the truth Your Honor, I have no idea why we paid for these items, this was a mistake, and we are not going to ask to recover that money".

Can you imagine this? They first indicate that they never pay for these things and then they admit they paid and made a mistake.

I think Alan has a fighting chance. And the Judge asked them if they ever received a pre-authorization about the orthotics and they lied and said: "no we received nothing from the shoe company"

Oh Really?? then how come Alan got SHOES!!!! Because the submission was made at the same time, both shoes and orthos were molded at the same time.

This whole thing makes me nervous.

I know insurance companies try to get out of paying for stuff, I know this. But the best was when the Judge said "Let me get this straight, Alan has neuropathy, you acknowledge that Alan has neuropathy, he has the same condition as a diabetic but you won't pay for the shoes because he's NOT A DIABETIC?? Even the judge sounded skeptical.

But the other side admitted this was so.

So how does one change the medicare guidelines anyway. I'm up for it.

Maybe that judge might think "oh my goodness, what if my mother or father gets neuropathy, but isn't a diabetic, you mean medicare won't cover shoes for them?

It's something to think about, no??

We shall see. And I'll update you all.

This will be a MAJOR discussion at the next Neuropathy Support group meeting.

Melody

[glenntaj]

--you did an excellent job on this, Mel.

Basically, as far as I can see, you caught them in a mistake at the very least and in a deceptive practive at worst.

The question is how far the judge's authority actually extends in these cases--and I admit I have no idea what the political considerations are. I couldn't even speculate whether the judge is compelled to follow the regulations to the letter, can bend them in certain cases, or is independent (and ornery) enough to want to make an example/teach a lesson to the other side and make them pay for their incompetence and/or deceit.

But Echoes is right; this is PRECISELY the type of thing that an advocacy organization should be lobbying abround, and bringing it up at the next neuropathy support meeting can only help. Wonder if you could get some of the administrators from the Association there . . .

[MelodyL]

Originally Posted by glenntaj

--you did an excellent job on this, Mel.

Basically, as far as I can see, you caught them in a mistake at the very least and in a deceptive practive at worst.

The question is how far the judge's authority actually extends in these cases--and I admit I have no idea what the political considerations are. I couldn't even speculate whether the judge is compelled to follow the regulations to the letter, can bend them in certain cases, or is independent (and ornery) enough to want to make an example/teach a lesson to the other side and make them pay for their incompetence and/or deceit.

But Echoes is right; this is PRECISELY the type of thing that an advocacy organization should be lobbying abround, and bringing it up at the next neuropathy support meeting can only help. Wonder if you could get some of the administrators from the Association there . . .

Forget about getting the Administrators fromthe Associatio there.

That's the first thing I did when Alan initially got denied. I called them, I emailed them. I got a very polite email response indicating that they don't do advocacy (I initially asked them to be a witness at the hearing (over the phone), or could they write a letter or SOMETHING. The answer was, regretfully NO, Then I contacted ANOTHER Neuropathy Organization, and asked the same thing. Same response.

So no help in THAT Department.

I AM WONDERING if the ACLU would get involved, (in case we get turned down again).

I asked Alan, "Is this as far as we can go, (the hearing with the ALJ I mean)? And Alan said "No, the next step is to go to an actual Court, but I'm not up to that". So I said 'So this is it?" And he said "I guess so".

Alan is on Social Security, and the foot company (A very very nice Foot Orthotic Company) knows this and probably won't pursue payment.

Immediately after I got off the phone with the ALJ, I phoned the Foot company and got on the phone with their billing department (we're old phone friends because of all these shenigans). I had her laughing on the other end. She said "You know, you should go to Court when I go to Court".

I told her "I'm just letting you know that we did do a good job of why your company should get paid, that my HMO did pay previously".

She said "Yeah, I know, but HMO's lie all the time and the judge's know this"

I didn't know that.

So we fought the good fight, and in a few weeks, we'll find out if we won the good fight.

Oh, on another note, I AM ENTITLED TO A PAIR OF SHOES EACH YEAR because I'M A DIABETIC RIGHT?

Wrong!! Same HMO as Alan.

Seems that when my podiatrist put in my prescription for my shoes (as he does every year), well this time, they only will pay $88.00 and that' NOT ENOUGH TO COVER THE COST OF THE SHOES. So we are finding out if my doctor's office will accept this payment. He is part of a practice and lately he said the HMO's only pay something like $40 for a pair of shoes. (I must be lucky, they paid $88.00 for mine).

I called up the girl who handles all the insurance (at my podiatrist, I mean). I asked her "If your office got paid the $88.00 and you are not satisifed with that amount, what happens next?"

Her reply was "Oh, we refund the money to the insurance company". This happens all the time.

So as soon as I heard that, I went to Payless and got a $20.00 pair of nice white sneakers (with a wide toe box).

That will work fine for now, but I guess I'm facing MY OWN FIGHT for my own pair of shoes.

But you see, I'm not complaining. I can go into any shoe store and buy a pair of shoes. Alan CANNOT DO THIS.

So if anyone knows who I can write to to have them re-think their medicare guidelines rule, let me know okay?

Oh, and this is interesting, when I was on the phone with the Foot Company representative I asked her if the judge has the discretion to side with us against the HMO, or if he had to follow the medicare guidelines as well.

Her reply: "Of course he has discretion, HE'S THE JUDGE, if he didn't have discretion, there would have been no hearing over the phone".

So she thinks we just might have a shot.

time will tell

lol

Melody

[echoes long ago]

i can see a neuropathy organization not wanting to come to a specific hearing because of lack of time or manpower but you would think that they could write up a standard brief that a person could submit as to why some non diabetic PNers have the medical necessity of orthotics and shoes. That California organization talks a good ball game but that appears to be all they do. Both organizations are absolutely useless. They should be working on getting the medicare rules changed at the federal level. What is it exactly that they do?

[MelodyL]

Originally Posted by echoes long ago

i can see a neuropathy organization not wanting to come to a specific hearing because of lack of time or manpower but you would think that they could write up a standard brief that a person could submit as to why some non diabetic PNers have the medical necessity of orthotics and shoes. That California organization talks a good ball game but that appears to be all they do. Both organizations are absolutely useless. They should be working on getting the medicare rules changed at the federal level. What is it exactly that they do?

I agree, so it has to be UP TO US to do DO THE WRITING AND EMAILING.

Anyone know who writes the medicare guidelines and who I can write to?

Thanks much

Melody

[Kitt]

Found these two sites from Medicare concerning shoes, etc. Interesting.

http://www.medicare.com/equipment-an...-footwear.html

http://www.medicare.com/equipment-an...tic-shoes.html

Government writes the rules???

[MelodyL]

Originally Posted by Kitt

Found these two sites from Medicare concerning shoes, etc. Interesting.

http://www.medicare.com/equipment-an...-footwear.html

http://www.medicare.com/equipment-an...tic-shoes.html

Government writes the rules???

HI.

Yes, I'm aware of the information that was stated in these two links. As a matter of fact, I'm going through it myself because I'm a diabetic and I also have neuropathy (although I was extremely lucky and got a handle on it because I take Methylcobalimin every single morning.

In MY case, I am entitled to orthopedic shoes,(I'm not in Alan's category, so I don't need custom molded anything), but diabetic shoes (let's just call them fancy sneakers with big toe boxes), well they are costly. But the HMO will only contribute $88 towards my shoes and my shoes cost much more than $88.00. Other HMO's pay as little as $40 towards the cost of the shoes.

That's why many shoe companies refuse to take the $88.00 and the $40.00 (unless the patient provides the rest of the money).

I'm on Social Security Disability and I grow my own food in my kitchen. If they think I can come up with a co-pay of $100 or more, they are kidding themselves. I mean, what's the use of having insurance if they don't cover SHOES for goodness sake.

Thank god, I don't need custom orthotics like Alan does. I DID need them over 5 years ago because I had a double heel spur (but surprisingly, I have had no problem with this condition for YEARS)

Okay, I just found out who takes care of all these things.

THE CMS
Centers for Medicare Services.

Here's the website

http://www.cms.hhs.gov/

Now THERE'S A LOT OF INFO AND LINKS AND THINGS TO CLICK ON, and there is even a contact link, but after doing that, I have no idea what to do next. I want to contact the people who make the policy, who make the guidelines, and request that they CHANGE the status on not allowing non-diabetics to get shoes and orthotics.

So any of you creative people out there, click on this website, scroll around and if you find a place that I send an email or call (about changing policy), kindly let me know.

I couldn't find it.

Thanks, Melody

[JoanB]

Hey Mel, this might be a longshot, but have you considered contacting your congressman/woman's office? I've heard of people getting help that way when it's a problem that involves the government. Just a thought.