yeah, botox with Dr. D was flat out denied for me. i went and did it and they paid for it. i know Dr. D's office is experienced in denials. he said most everything is always denied at first.

I sucessfully appealed once and have been deinied twice. mine only covers 16 per year. Last year I was able to get it extended to 28 visits. I had to send in letters of med necessity,records, my own letter etc. explaining why I needed to continue. Now I have secondary ins which I hope will pick up when I run out. I have been dong pt continually for almost 2 years.

I'm in my first appeal process for claims dating back to 12/1/12. My insurance has "unlimited PT," but this really means nothing. I've submitted the documents that they requested, and now I wait. The frustrating part is knowing the nudge making the decision is even less knowledgable about neurological entrapment and compression disorders than the countless medical doctors who've examined me.

Ironically, is it even possible for patients with TOS or brachial plexus injuries to abuse PT? If you go to frequently, you're body isn't timid to tell you.

I'm also in appeal with a PT I saw last summer who billed for 1 hour and 15 minutes of therapy (5 modalities), but I was in her office for 15-20 minutes. She billed for 30 minutes ($120) of therapeutic exercises which consisted of lying on a foam roller for 5 minutes. She seems to have disappeared into the woodwork when I called her on her "creative billing," but I may pursue an audit on her facility as she is the reason why we all fight to get the care we need.

I asked the three docs to write letters and they will again. But their first letters did not work. I also am asking for office notes to be sent.

It really is upsetting and very expensive. My PT is wonderful and very committed to helping me. She learned the edge low program.

Ask for a case manager with your insurance company. Also if your policy is through an employer have your HR rep contact your case manger as well. You need to get your Dr to write a letter of medical necessity and outline why the surgery is more dangers. Also Dr d can request a Dr to Dr review for approval. Most often the employer GRP determines those medical reviews.

Ok will ask for a case manager and will call hr. thank you!

I WANT YOUR INSURANCE!

Sorry GRP is group

Called and got a case manager. Not helpful they do not help with getting coverage just questions about medicine etc. also called human resources and they told me I need to. Exhaust appeals before they will help me.

Iris: Do you know if your insurance plan is self-insured (self-funded) through your employer? If it is, the HR Rep may be sending you through the process, but ultimately, it's up to your employer whether or not to pay the claims. A self-insured plan assumes the risk, usually with some stop-loss in place for catastrophic claims. Your PT claims are a pittance in comparison to a potential catastrophic surgical claim or even a surgical claim with the same amount of PT to follow.

My plan is self-insured and although I have to go through the appeal steps, the company would be financially insane not to pay my PT claims. I'm chump change in the big picture of their potential exposure.