Insurance refuses to pay for Alan's custom shoes
 

Well, now I've heard of everything. I wonder if any of you have faced this problem.

Last year, his insurance company (he's on a medicare HMO), approved his custom molded shoes. He can't wear ANY OTHER TYPE OF SHOE EXCEPT THE CROW BOOT.

So when the foot ulcer is debrided and he can walk, he MUST WEAR THE CUSTOM MOLDED SHOES.

And his podiatrist told him a few months ago "Alan, your feet need new shoes every year, 8 months would be better but definitely every year".

Now I don't need to tell you how much custom molded shoes are.

So when he got his pair LAST year, we were elated, and he got to walk outside and have SOME quality of life.

So this year, ( a few months ago), he needed a second pair. His podiatrist wrote the prescription noting that he needed an outer wedge on this new pair of shoes because he slants over on his heels.

So he went in for the custom molding. All was done and several weeks later Alan had his new pair of shoes.

Well, we just got a letter from the insurance company saying that the Orthotic company that makes his shoes submitted a claim and the claim was denied.

Reason for denial??? NOT MEDICALLY NECESSARY. That's right, the brain dead physicians at the insurance company have come to the conclusion that based on his benefits, this is NOT A MEDICAL NECESSITY.

Not a medical necessity? The guy can't walk without these custom molded shoes.

How is that NOT A MEDICAL NECESSITY??

Of course we called and they said "All you can do is appeal, get a note from your doctor (we did this last year but we didn't need to appeal last year).

These custom molded shoes are extremely pricey (as you all must realize, right?)

Of course, we wrote a letter of appeal, and I just got off the phone with the podiatrist's assistant (who handles all of this), and she said "we deal with this all the time, insurance companies decide that unless the shoe is fitted with a brace, it's not a medical necessity".

I said 'Can we get a letter from the podiatrist, maybe this will have some weight with the other physicians who ultimately came to the conclusion that Alan doesn't need custom molded shoes".

She said "no problem". So next podiatric visit, we'll go and pick up the letter.

Have any of you dealt with this (I'm sure you have), and what was the outcome.

Remember, Alan is NOT a diabetic, and for some reason, this SEEMS TO MEAN EVERYTHING TO INSURANCE COMPANIES.

Me?? I'm a diabetic and I get new diabetic shoes every year.

But because this guy has peripheral neuropathy, foot ulcers, all these things on his feet which necessitates CROW boots, custom molded stuff, etc. AND HE'S NOT A DIABETIC, we'll they'll just throw him to the dogs.

Sad stuff, no??

Melody

I ran into a similiar situation, because my PN was not caused by diabetes i could not get orthotics paid for that diabetics could. Its medicare rules that the insurance companies then adopt. Seems like discrimination to me , but diabetics have a much better lobby.

Each year the insurances tighten rules, add tiers to drug copayments etc.

All you can do is be vocal and fight it. Pointing out how much more money they will be forced to spend on Alan, without these protective shoes, may be one aspect you can use to hammer home the complaint.

Very often if you make a big enough fuss, you will get the benefit. It is just aggravating as all get out! :(

Melody not over this particular situation but I have seen insurance pay for things more likely because of having diabetes.

Also sometimes if the doctor rephase what he wrote down, and write it differently, as a medicial condition, sometimes then they do pay.

Keep fighting it hun, hopefully it will get straighten out and they will pay.

Trish :grouphug:

Anybody been watching the health care reform on C-Span, I can't print what I think of it so far on this forum. If these clowns suffered from chronic pain there might be some degree of intelligence displayed. You can bet a whole lot of **** is going on in the back rooms. Enjoy the day after all your government has your best interest in an amendment. :eek::eek::eek::eek::eek::eek::eek:
Lanny

Diabetes is usually spelled out and you are out of luck if there is another cause.

i wonder if it is because every trial for every type of medication or device for peripheral neuropathy is only tested on people who have PN due to diabetes. The reason of course they do the tests on diabetics is because they know the cause of their pn so that variable in testing is controlled. When you read the results however, it states that the product or drug was effective in treating some aspect of diabetic neuropathy. Those of us with other causes are left out in the cold and therefore perhaps those devices or treatments are not recognized as being effective for our type cause of PN.