Alan LOST the appeal for his custom Inserts
 

Well, this beats everything.

Oh, just to clarify, his Medicare HMO PAID FOR CUSTOM SHOES WITH CUSTOM ORTHOTICS FOR 2 YEARS, but in 2009, they paid for the shoes but not for the orthotics.

About two weeks ago, we had a telephone hearing with the Administrative Law Judge because we appealed the Medicare HMO's decision not to pay for Alan's custom orthotics (inserts)

The ALJ listed to all sides and the insurance company admitted paying for the shoes, also admitted they made a mistake and SHOULD NOT HAVE PAID FOR THE SHOES in 2009, and SHOULD NOT HAVE PAID FOR BOTH SHOES AND INSERTS in 2007 and 2008.

So we are all on the phone trying to get the judge to order Alan's medicare HMO to pay for the Orthotics.

Alan also needs new shoes for THIS YEAR.

At the time, the judge seemed VERY sympathetic to Alan's cause and even asked the insurance company "let me get this straight, you are denying Alan's orthotics because he is NOT a diabetic, but you acknowledge that NEUROPATHY in either case is the same disorder.

The other side said "yes, but we have to go by medicare guidelines".

I really thought I had the judges ear and hoped that he would over-ride that medicare guideline thing.

Well, this is what the last paragraph of the decision letter said. (On the first page it indicates that the decision is UNFAVORABLE).

Get a load of this paragraph. and the next!!!

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

"the undersigned ALJ understands that it must be very frustrating to know that Medicare will cover custom shoes and inserts for diabetic neropathy, but not for peripheral neuropathy, as such a limitation places form over substance. The undersigned, however is bound by the legislatively created exclusion of orthotic shoes and inserts from Medicare coverage, unless to treat diabetic neuropathy.
Conclusions of Law
The applicable laws, regulations, policies and contracts do not obligate the Plan to cover the items at issue in this appeal. Section 1862(a)(8) of the Act, NCD No. 280.10 and the Plan's Evidence of Coverage exclude Medicare coverage of orthopedic shoes, inserts, or other supportive devices for the feet. The Appellant does not qualify for an exception to such exclusion because he does not have diabetic neuropathy.

Order
The appeal is denied. An unfavorable decision is entered for the Appellant.


Now in the first pages, it does say that he can appeal this whole thing. There is a form Called Request for Review of Administrative Law Judge (ALJ) Medicare Decision/Dismissal

So our next step would be to APPEAL THIS DECISION, RIGHT?

Would any of you do this?

I mean, here's my question.

IF THE JUDGE SAID HE HAD TO FOLLOW THE MEDICARE GUIDELINES, WHY THE HECK DID WE HAVE TO HAVE A HEARING IN THE FIRST PLACE??????????????????????????

Any comments are welcome.

melody

That is just terrible.

Can you pull the inserts out of the shoes, and put them in the new shoes?

The distinction is something I don't understand either. I have the same issue with our state insurance fund for the "uninsurable". There is a 24-month wait before I am eligible for Medicare. Because my SSDI benefit is above the income limit I'm not eligible for Medicaid. But, if I had diabetic neuropathy, I would have one of the 50 disorders that qualifies as uninsurable, and would therefore be eligible for that insurance fund.

It makes absolutely no sense to draw any distinction between diabetic neuropathy and peripheral. But since there is a distinction, it would seem that a person with diabetic neuropathy in theory has more control over their neuropathy than a person with PN of unknown origin. At least a diabetic knows the underlying cause and can treat that. But, a person with PN of unknown cause can only treat the symptoms, which in my mind would make them more in need of assistance.

My 2 cents: You have gone this far. Appeal the appeal. You have nothing to loose. Good luck to you and Alan.

Well, Alan has a pair of custom molded shoes (with inserts) from 2008 and a pair of custom molded shoes (with inserts) from 2009.

You see, the company that made the shoes and inserts ASSUMED Alan's insurance company would pay because they did so in 2008 and they paid for the shoes in 2009.

So when the shoe company was DENIED for the inserts they said "wait a minute, you paid for shoes and inserts in 2008 and you paid for the shoes in 2009, BUT YOU WON'T PAY FOR THE INSERTS??"

This all was told to the judge and he sounded sympathetic but it made no difference.

So to answer your question, I would assume Alan could switch inserts in both pairs but he can't put these inserts IN REGULAR SHOES.

He has to have CUSTOM MOLDED shoes.

We just paid money to have both pairs of shoes re-sold.

But as for the inserts, well, they need to be replaced every so often because they wear out.

See, we can re-sole the shoes, but we can't fix the inserts.

And now that the shoe company knows that his HMO is NOT GOING TO BE PAYING for anything, I would gather they are NOT going to measuring Alan for any more shoes or inserts, right?

And Alan was due to get new shoes for 2010.

This is not going to happen.

oh well.

Melody

Thank you. I believe we will take the next step.

Oh, to show you how screwed up the medicare guidelines are: I AM A DIABETIC and I'm supposed to get new shoes ever year. But because medicare will only pay $88.00 towards my new shoes and the won't pay a dime for any inserts, the company that makes diabetic shoes won't accept the $88.00 that medicare will pay.

So I went to Payless and purchased a regular $20.00 pair of sneakers.
Alan can't even do that!!!

what a shame.

Melody

I remember back when a few of us came to Silverlady's rescue when she was faced with a tough situation. I for one would be willing to pitch in and help, I can't set it up though b/c my computer skills aren't that great...... I don't have loads of money but I can help if it makes life easier for you and Alan. This is all such a load of hooey, all for a pair of shoes!

Anything along these lines of financial support, would have to go thru the administration team here for permission.

Silverlady's special case was approved.

If this develops further please contact Chemar.

Actually i am surprised that Alan would get new shoes every year, whether or not he had diabetes. Mine are expected to last a lot longer than that - two years minimum, often longer. Mine don't get paid for, although my orthotics (which are molded into my braces) are free and get replaced about every two to three years. My current shoes are about 18 months old and still going strong, and I got new braces (AFO's that come up to my knees) with orthotics moulded into them just before Christmas.

Sorry if I am being really dim here - can't he wear the one's from last year? I do, and I can't wear regular shoes. I only ever have one pair of shoes at a time that I can wear, and I am just used to this.

Hope you get all this sorted soon
raglet

I think it would be great if you have the energy and appealed. The whole situation is rediculous. The ALJ can see that the rule is rediculous but is not allowed to modify it apparantly. Neurologists and PN advocacy groups are all useless. Where were they when these medicare guidelines were proposed and instituted? Send a copy of the correspondence and decision to Senator Gillebrand. She is up for election this year and has been active on several fronts related to health care.

How kind of you, but don't worry. Alan already has the two pairs of shoes and these will see him through whatever he needs to be seen through.

But aren't you a sweet person for even thinking of that. Very nice of you.

We are going to appeal and we'll see what happens.

What I want to know is why on earth we had to have a telephone hearing, be sworn in, give testimony IF THE ALJ was going to go by medicare guidelines. Didn't he know BEFORE HAND that he would have to go by medicare guidelines?

This can't be the first time he had something like this before him.

I do NOT understand this whole concept. I mean, if the judge was able to find in Alan's favor, then I could understand the hearing.

But if you read the decision, well, it seems to have already been decided.

See what I mean?

What the heck is the Judge good for?

Melody

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

I absolutely agree with you Mel--
 

--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.

And I just composed a letter to Letter to the Editor (Under Voice of the People) in my local Daily News newspaper, which reaches LOTS OF PEOPLE.

Let's hope they print what I wrote. If they do, I'll find it online and share it with you all.

Oh, I went to our monthly meeting of the Neuropathy Support Group last Thursday, I'll do a post on that.