Hi, according to Alan's doctor, (and he put this in writing), Alan's neuropathy is so severe, and his foot ulcer is. well, it is what it is, that Alan actually needs shoes EVERY 8 MONTHS. I was there when he told us this and wrote the note for the insurance company.

Alan cannot have any foot surgery on his foot ulcer because of his neuropathy.

So it all has to be SHOES and special INSERTS that have to be molded to his foot and then done in a way so the foot ulcer free floats.

And believe me he tried, off loading shoes, and other things.

And with our HMO it says 'diabetic shoes, or a shoe with a brace, only if a person is diabetic' and that is once a year.

So Alan will make do with has. We just had them re-soled and the guy did a marvelous job.

But now (and this applies only to me)they only pay $88.00 for the diabetic shoes and I'm entitled to inserts too. I just got the denial from my HMO (same one as Alan's), and they denied my inserts. So they would pay $88.00 for my shoes but will not give me inserts.

And the thing that really confuses me is the his HMO paid for his CROW boot? Do you know how much a CROW boot costs? A LOT MORE THAN THE SHOES.

What nutty rules they have.

Melody

My orthotics are replaced every two years....no sooner. Shoes are not covered, but splints and braces are....after a copay.

I imagine if the law STATES something specifically, then the lawyers stick to the law. To them it is clear and they don't like ambiguity.

You can be a burr under their saddle, but just don't invest emotionally or financially. Thank God it isn't chemo or life saving surgery.

Law is not justice. Law is not fair. Law is not ethical. Law is what some governmental body agreed to....just think about women and the vote. The law once stated that people of a certain skin color were 3/4ths of a person...and remember the Salem witch trials?

It stinks after you invest so much energy, and it seems totally illogical to not cover it for PN from any cause...It depends on which disease lobby gets to the law makers first, or most generously.

Actually, this SCREAMS of discrimination. To differentiate between Diabetic Neuropathy, and Peripheral Neuropathy is well, DUMB!!!

Even the judge said 'are you telling me you won't pay for Alan's inserts because he's NOT a diabetic?" and the insurance company said; "yes, don't blame us, blame medicare guidelines".

So, besides appealing, I am going to try and reach someone who writes the medicare guidelines and have them them say something to the effect:

"People with neuropathy (no matter what the reason), if their doctor says it's a medical necessity and they need custom shoes and custom orthotics, then this should be covered under Medicare (or some such wording).

I'm flying blind here, I know, but this will impact a lot of people who can only wear custom shoes. The only other recourse is a wheelchair.

And I find that very sad.

Take care,
Melody

--it is a stupid distinction, and, yes, it seems ridiculous to put you through the whole process if the decision due to statute was preordained. I imagine the fact that stuff was paid for in error may have also had soemthing tod o with this (and there may have been pressure on the judge in that regard, too).

I would go through the continuing appeal process--not so much for the reimbursment, but for the PRECEDENT. Remember, we're currently in a BIG push for health care reform. Even if the current bills are passed, they are likely to be revised/tweaked in the future as the consequences/effects are gathered. I would take your story not only to the Senators, but to your Congressperson (who is yours? is it McMahon?--if it is, he's not that thrilled with health care reform, but I have friends in Staten Island who know him, and should be able to get you through to his constituent office) and the local State legislators as well. And, since the neuropathy organizations don't seem very helpful here, it's time to go to the press . . .

When things are stupid, they need to be changed.
Do it to try to set precedent, Mel. And take Glenn's assistance
with the politicos.

I'd also try the media. Now is the time! with all the health care reform being a hot topic!

Can his doc re-think the diagnosis and focus on the ulcer alone and not the PN. Drugs, medical procedure, tests, etc are many times tied to a diagnostic code. If Alan had a chronic foot ulcer in which he could not have surgery what would his doctor prescribe. I guess I'm asking if there are other reasons that insurance will cover orthotics when it's not related to diabetic PN; and does it apply to Alan?

Just a thought.

Marlene

Marlene:

Under medicare guidelines, the only time you can get shoes or orthotics is if you have DIABETES, a DIABETIC DISEASE, or if you need a shoe attached to a brace (you then, DO NOT HAVE TO BE A DIABETIC,), but you need to have something like MS, or Charcot, or something in that your disability requires you to wear a shoe that is attached to a brace.

Since Alan's shoe is NOT attached to a brace, he is not qualified. This was said during the telephone hearing also.

So he doesn't qualify. I will look into the media thing. (I have had two articles published in VOICE OF THE PEOPLE in the New York Daily News).

I'll give this another try. Then I'll contact the political offices, and if I need assistance, I'll ask Glenn

I'll mow them down!!!!

lol

Long Live Free Speech

And FOOEY to Judges who don't have compassion. I wonder how he would feel if his mom or dad got neuropathy, and god forbid they weren't a diabetic.

Will update

Melody

Glenn:

I just found Congressman McMahon's official website and got his contact information. I wrote a very good letter to him. I put in all the details and asked for his help. I shall let you know if I hear anything.

And now for the voice of the people.

Here I go!!!

lol

Melody

im sure you will hear from McMahon. He is up for a tough election in november and may be challenged in the primary as well. He has also been one of the representatives who has not decided on how he will vote on the health care bill. Strike while the iron is hot.