Insurance Co.won't pay for his orthotics
 

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.:ranting:

I have the feeling--
 

--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.

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.

That's possibly true, but it stinks nonetheless.

To discriminate against someone just because HE IS NOT DIABETIC, and even to acknowledge the fact that he NEEDS THE OTHOTICS and the CUSTOM SHOES to walk otherwise HE CAN'T WALK, well, to me, it stinks.

I was on the phone with Maximus 7 days ago (before I got the denial). I wanted to know where they stood and if they made the determination. The lady on the other end said "We'll be making this determination next week".

I then carefully and politely explained all about Alan's neuropathy and ulcers and she listened and I said "am I getting through to you at all?" and she said "oh yes, and we often disagree with the original decision and we reverse it?" and I said "you mean, this might just turn out favorably for my husband?" and she said "absolutely".

Well, ABSOLUTELY didn't come did it? They turned him down.

What stinkers.

melody

I got a letter telling me they didn't want to pay for any more IVIG, and if I pushed it, they would deny me retroactively, which would have left me with a bill of 70-90K$. That smacked of something illegal. Kind of extortion like.

They reversed themselves, after I fought it. Can you imagine telling the patient that not only will they not pay for future treatment, but also that they would come after you by denying retroactively, if you tried to fight it!

Insurance companies are dirty.

Anyway, they are now paying for my IVIG and admitted a mistake. Mistake my....They thought I would not contest for fear of being saddled with a huge retroactive denial.

My daugther is sitting with an 8K bill because the procedure she had has no code. She has appealed and is fighting it.

Don't get me started on insurance companies....

A few years ago, i was told that i needed orthotic inserts. I was denied by my insurance company and they told me that they follow medicare rules and that shoes and inserts are only for diabetic peripheral neuropathy. So this rule goes back at least 3 years. In my opinion this rule is a result of all of the clinical trials for anything concerning peripheral neuropathy being done on those with diabetic peripheral neuropathy only. Discrimination at its finest. Its totally assinine. Its the same disease just with a different cause. I wound up having to pay for them myself.

To Cyclelops:

Scariest story, jeeez. I told Alan, don't mention anything about IVIG, he replied "I'm not scared of them" Oh brother.

To: Echoes:

Thank you so much for sharing. It's discrimination at its finest, isn't it?
I wonder if we could get the ACLU involved. Maybe they could accompany us to the hearing?

Mel

im with alan, im not scared of them either. At least you are getting a hearing, most of these people you can never get to answer the phone....voice mail has become a convenient way to ignore you.

this situation is exactly where an advocacy group should step in to try to rectify this whole only for diabetic neuropathy criteria. I remember reading about an advocacy group in california for people with PN but havent heard anything about them in a few years.

Well, I'll be contacting the ACLU (don't know who else could help), will update you all when I know ANYTHING.

until then, crossing fingers toes and everything else. (including my sprouts)

mel

You migth want to get the Neuropathy Association involved--
 

--since they're always looking for ways to get more publicity for the condition and the difficulties in treating it.

www.neuropathy.org (and I think there's a phone number fo the office on the website--and you guys are part of a sponsored support group, correct?).

WHAT A SUPER IDEA!!!

Well contact them today.

You're an angel!!!

Melody

Well, THAT WAS A DEAD END!!!

Just got off the phone with the Neuropathy Association. We are members in good standing, (meaning paid up).

I told him Alan's problem and asked if they had any advocacy person, or can they do anything to help Alan, (for example, have someone come to the hearing), or do ANYTHING to help our cause in dealing with HMO's.

The guy was very nice but explained that "no, we don't do anything of that nature, we once tried to get an advocate but there is no funding and we are not a big enough group to do this" I'm just quoting exactly what he said.

Amazing, no??

Melody

This is the group i was thinking of

http://www.neuropathyaction.org/about_naf/index.htm

Thank you Echoes: I just sent them an email.

I also just found the statement from his HMO from June of 2008 indicating that they did indeed pay for the shoes and inserts.

I wonder if I should bring this to the hearing and say "well, you paid for the shoes and inserts last year, and this year YOU PAID FOR THE SHOES, so why not pay for the inserts?"

Think this might have any affect on what the Judge decides?

Mel

I would certainly bring that evidence to the hearing.
 

And I'm sorry you didn't have much luck with the Neuropathy Association. (I have criticized them in the past for not being a really strong advocacy organization, and not aggressively pursuing funding, famous people to talk about the condition, and all that, but you'd think they might have been able to refer you to someone.)

I'm not as familiar with the organization echoes mentioned--my sense was that they were more West coast--but I suppose we should check it out.

The TNA doesn't even have a moderator for their BB. It can run wild, and they never even bother to check it out- unless someone calls them and mentions that something's wrong.
I don't bother to pay dues anymore cause I'm not so sure that they
do anything other than look for medical research that is already being done.

They don't seem to initiate anything, or do anything for sufferers.

They also aren't transparent in their use of funds.
They refuse to unveil where the money goes.

Oh, speaking of BB and message boards for The Neuropathy Association, I initially went there to post my question about them helping my husband with an advocate when he goes to his hearing before the ALJ.

I went to the website, and emailed them. I got an auto-responder telling me that they don't answer people back and that I should go to the Bulletin Boards.

So I went to the Bulletin Boards. Lots of messages but no where to register if you want to post a question. You can view messages as a "Guest" but can't post.

THAT'S WHEN I PHONED THEM. I got a very nice man (the one who told me that they don't have the funds to help people), and I told him "I'm at your website and I'm at the Bulletin Boards and I don't know how to register, can you help me'. He said "hold on while I bring it up at my end".

He poked around and said "oh my, you are absolutely correct, there's no place for you to register so you can post" He said he would ask the experts at his end how I could rectify this (the point is moot because he answered my question anyway) but I still wanted to be able to post (for any future occasion). He said he would phone me back when they figured out how to allow people to register to be able to post on their bulletin boards.

I'm not holding my breath. But he was very nice and pleansant anyway.

Mel

What Alan is running into are based on national medicare rules that insurance companies follow, so contacting the advocacy group in California may help if they have had any experience with the problem with shoes and inserts for people who have non diabetic pn. And really who better to call them than Melody, shes not shy.

Just the phrase diabetic neuropathy annoys me. Its peripheral neuropathy with a cause attributed to diabetes and really lack of circulation caused by diabetes. I know diabetics have additional problems with PN because of their lack of circulation and terrible problem with wounds and infections but really there is no such thing as diabetic neuropathy. We all have peripheral neuropathy. You would think that this is something an advocacy group would address.

Echoes:

I just got an email from the Neuropathy Action Org.

Here's what they said:
----------------------------------------------------------------------------------------

"Thanks so much for contacting the Neuropathy Action Foundation (NAF). I am so sorry to learn about your husband’s struggles. It always amazes me how health plans treat folks to save a buck or two off of their bottom lines.

Melody, your husband’s situation is very tricky. Since this will be an ALJ hearing, you want someone who can be present with you at the hearing. I would try contacting the Medicare Rights Center at http://www.medicarerights.org/ since this is a Medicare issue. The Medicare Advantage Plans (HMOs) deny coverage left and right and unfortunately seem to get away with it, however, keep on fighting the good fight until you have no options left. After doing a little research this is the only thing on the Medicare website I can find about custom shoes or orthotics http://www.medicare.gov/Publications/Pubs/pdf/11022.pdf. It pertains only to diabetics though once again.

Melody, I am so sorry I do not have stronger suggestions but definitely look into the Medicare Rights Center. Best of luck to both you and your husband."

-----------------------------------------------------------------------------------------

so at least they were kind enough to respond. I'm going to look into those links, but I'm not holding my breath. I guess I'm looking for an ALJ who will consider a COMPASSIONATE EXCEPTION.

I wonder if they ever grant these things???

Melody

If the ALJ is employed by the insurance company i wouldnt get my hopes up, however you should bring all of your proof of receiving shoes, inserts etc. in the recent past.

This is exactly the type of a thing that an advocacy group for a particular disease should be seeking to change. That is the problem with so many things related to medical care such as the new medical insurance bill, electronic records etc....way too much lawyers input, insurance companies, doctors and no patient input or representation on boards.

How do I find out if the ALJ is employed by the insurance company?
thanks, Melody

http://www.nyconsumerhealth.org/rights5.html


at this site is a detailed explanation of the process. it states here that most appeals are over durable medical equipment and orthopedic devices.


http://www.cumc.columbia.edu/dept/al...cal_update.htm

THANKS VERY MUCH.
Going to check out those links.

Melody

Well, I checked out both links. Very complicated but it's clear to me that it's all about Alan not being a diabetic. Nothing we can do about that. The plan states what the plan states.

When we get the hearing date, I'll go with him bringing proof that they paid in the past, and they also paid for his shoes in 2009. Don't know what the ALJ will say when he sees that they did indeed pay for shoes (even though they were not supposed to (as they put it).

Maybe he'll side with Alan, maybe not. Nothing more I can do except contact the ACLU.

I think I just might do that.

Melody
P.S. THANKS VERY MUCH

Mel
 

Thanks for posting this ,been sitting around doing what,use to drive my husband crazy, I worry about everything even if I don;t know if I need to be.

Almost always things work out...For instant I had a appointment with my Nuro about staying on the IVIG,but I was in burn and wound ICU for venostassis injury.. I asked the icu nurse to call the neuro to call the dr.,who to ask for and could she make a appointment,there hard as some of you know to get into. well she called forgot who she should ask for and why,even
through it was was written down,oh well.

Anyw I have compression hose made in Gerymany every 6 months because
rhey feel they help better with the venotasis ulcers. I pay for these but told the Dr. he good taste was breaking me,then for the cmt they want to straighten my frrt,the shoes are paided for because of diabetethes ere paided for,I don't know about theorthonics yet//

Mel so far i've had Drs. help me,but i've bee n lucky,but lately the rules keep
changing,just take the biggest stack of med, papers you have,and like Glen
said depends on how the jude feels that day,and C is right be glad you you got a hearing,but oh boy it makes you tired,after all stress makes you sick.

Good luck to us all and good grief here we are doing there job. :hug: Sue