Help with Insurance appeal

[Choc_marg]

Background:
DS5 was born with severe kidney reflux. After a year of tests & hope that he would grow out of it (he didn't), he had reimplantation surgery. That appeared to work for awhile, but his kidneys never completely healed. They have always been enlarged. So after more tests, it turns out that his bladder doesn't communicate with his brain and he was holding 3 times the amount of urine that a normal kid his age should be holding. The bladder couldn't hold it all, so it was backing up into his kidneys again. There was no neurological reason why (no spial cord injury & no spina bifida - confirmed with a spinal MRI). At this point, the docs (we got a second opinion) think that because of the severity of the reflux, his bladder never learned how to sense that it was full.

So, this past summer, he had a pretty intense surgery to enlarge his bladder by using a section of his colon and to create a channel (using his appendix) that connects his bladder with a stoma (button shaped opening) in his abdomen. So the only way he can drain his bladder is through a catheter placed through the stoma. This has to be done every 4 hours. Apparently the insurance policy that DHs company has does not cover "incontinance supplies". So, we have been denied insurance coverage for the catheters, but have been told that we can appeal for the insurance to bend the rules.

We have already sent a letter from the doc about the medical necessity. That was part of the initial inquiry that was denied. Now, we have to send our own letter to start the formal appeal.

Does anyone have any ideas on what to say? What works? What doesn't? Any experiences would be greatly appreciated. The medical stress this summer was enough for us. We really want to get this resolved so that we can get back to our lives.

TIA - Teena

 

[Choc_marg]

bump - anyone have any experiences???

 

[bettyann29]

Did the dr also send medical records? or just send a letter saying that he believes your child needs this?? I work for a health insurance company and have worked in the insurance field for years and have worked for some major health insurance companies and its really hard to say what works.. What works for one might not work for another.. If its a direct exclusion on the policy its gonna be a little harder.. But my suggestion is to have the dr write another letter or if you have a copy of the letter he sent (he can probably get a copy of it for you as they most likely put a copy in your sons file).. along with his medical records and then a letter from you on your side of it and send it all together..

If he just sent a letter without the records than it might not do any good as they are going to look at the medical necessity of it, not the drs opinion.. Insurance companies generally have a Medical Director that will get those records and go thru them.. They are MD's so they know their stuff..

I would make a copy of everything before its sent and then start there.. Sometimes it takes reappealing.. Unfortunately sometimes the squeaky wheel gets noticed.. if you know what I mean..

 

[Choc_marg]

Thanks a bunch. I actually have copies of his records that I can send. I am pretty sure that the doc only sent a letter. I will request a copy of that as well as his original letter.

I think that even if we have to pay for a special addendum, we'd be OK with that. These expense of these catheters adds up quickly!

Thanks for taking a minute to give me some pointers.

Teena

 

[RNMOM]

I agree with the above poster. You need more detail. His condition has nothing to do with incontinence it is a "rerouting" issue. I assume by your description it will be a life long issue? You might speak with the office staff of the urologist who did the proceedure. They are often aware of what it takes to make the insurance companies happy.

Also want to add...when I have had issues I have spoken with the benefits department of my DH's employer and within a few days I have usually gotten a positive response from the insurance company. They don't want to make that big an account unhappy, ya know.

Best of luck with all this and give your little fella a hug for me.

edited to add: If you are unsuccessful, try having the office staff/social worker/yourself contact the manufacturer of the catheters. They often have programs in place to assist with medications and I bet many have also helped with durable medical equipment which I believe this falls in that catagory.

 

[AlexandNessa]

This article may help:

http://www.prevention.com/article/0,5778,s1-1-63-63-1828-1,00.html

Good luck in your fight.

 

[mtdevine615]

I work for an insurance company but we don't do health insurance. My advice to you is; keep all your records (every piece of paper they send and you send to them), keep appealing the denial (squeaky wheel gets the grease), send a letter to the state insurance commissioner for help plus your state and US reps and senators (that's what they're there for), if all else fails hire a lawyer. I know it can be daunting but don't give up.

 

[golfgal]

The letter from the dr stating that this is medically necessary SHOULD be enough. I know that when I was suffering from severe menstrual cramps the dr put me on birth control pills to help with that, they were not covered under our insurance. All it took was a call from me stating that the pills were for a medical condition not for actual birth control, although we used them for that as well. Sometimes it is all in how the dr's office sends in the claim, which codes they use.

 

[barkley]

choc marg-i'm so sorry to hear of your ds's medical issues!

i appealed an issue with our health insurance and won the battle by getting the doctor a copy of the pages in the 'evidence of coverage' book that specificly spoke of not covering the item along with the definitions page that defined what they termed the uncovered condition as being (they did'nt include the diagnosis we were dealing with in the definition). so the doctor was able to call the provider and specificly state that the exclusion did not apply in our case.

while you are fighting with the insurance company you might check and see if there are any other resources that might step in to help out. i know when i worked in social services (in a medicaid type program) we had parents apply for kids who were in the same situation-while they usualy did'nt qualify (because of their private coverage) there were some groups that helped out. st. judes childrens hospital was realy good about helping out kids whose insurance did'nt cover certain procedures, treatments and supplies-they also had staff that was realy informed as to resources-even if there's not one in your state you can contact them and they might provide some local resources. there are also some supply companies (along with pharmaceutical manufacturers) that if you contact them directly have programs where you can get the items at a hugely reduced rate vs. what you have to pay retail (some situations they do it at close to cost). the american kidney foundation might provide some good info. as well.

you might also try and talk to someone who does insurance billing for a kidney specialist. generaly they know how patients have achieved success in getting items previously denied covered (it's like with me-i had to read thousands of ssi denials, appeals and approvals-so i can tell someone what to provide from day one of an application to increase their chances of avoiding an initial denial and delayed approval).

best wishes to your family-you are in our thoughts and prayers.

 

[janey99]

Is it clear to the insurance comapny where the cath is being inserted?

I could see them saying a penile/urethral cath exiting through a normal body opening is an incontinence item, but a cath inserted into a surgically created stoma surely must be considered differently.

Hugs, and best of luck to you.

 

[mickeyboat]

I agree with everything sadi above, and have another recommendation.

Contact the HR department, and ask them to let you speak to their agent. Our agents have been instrumental in helping employees get coverage for services previously denied. Besides, they need to do something for their commission!

Good luck.

Denae

 

[Choc_marg]

Thanks a bunch everyone!! I knew that I could get some good pointers here.

Yes, this is a lifelong situation and that is why I want to get it resolved up front. We probably could just pay for the catheters, but they are expensive single use catheters and I think it is worth the fight to get them covered.

I would think that the letter from the doc would spell out where the catheter is being inserted, but I haven't seen it, so I'm not positive. I have a call into the office requesting the most current records including the letter from the doc.

Luckily, right now, we are working with a fantastic medical supplier that is supplying us with catheters as long as we need them without charging us. They are confident that we will get the insurance ironed out. I just don't know how long they will be willing to continue their generosity.

I will get on the ball & follow up on your suggestions and hope for the best. I plan to fight for a long time yet. I just hope I don't get discouraged along the way.

Thanks for all your support. The process was difficult and the recovery took all summer, but it isn't that bad to deal with and the positives far outweigh the negatives. We have already been given the great news that the kidney have begun to deflate and my peanut 5 year old has grown 2 inches since late June!!! We don't have to go back to the doc for a year. This is the best news we have received in 5 years!

Barkley - you wouldn't guess there is anything wrong with him by looking at him huh? We had such a rough summer (it was very difficult for his 7 year old sis too), we decided to go back to DCL to have our vacation & celebrate. We are on another Eastern on Oct 28. Hopefully we will be able to do Lord Sheffield this year!!

Thanks for all the hugs & word of wisdom everyone!

Teena

 

[HERSEY]

I handle health insurance claims. I don't agree with that decision, that exclusion is not applicable in your son's case. I think they incorrectly denied your claim. Just state your son's condition is not due to incontinance but due to a documented medical condition. Also attach a letter from your son's doctors. Second level appeals must be by a who was not previously consulted. If necessay after this level request your son's file to be reveiw by a peer review panel. This may not be necessary.

 

[Choc_marg]

I handle health insurance claims. I don't agree with that decision, that exclusion is not applicable in your son's case. I think they incorrectly denied your claim. Just state your son's condition is not due to incontinance but due to a documented medical condition. Also attach a letter from your son's doctors. Second level appeals must be by a who was not previously consulted. If necessay after this level request your son's file to be reveiw by a peer review panel. This may not be necessary.

I really think that it was a in/out quickly process. The just looked at the black/white of it & didn't read the letter from the doc. We are taking the next step & will definitely keep this info in mind if we need it. Thanks for giving your expertise. I'm glad to know that I am not completely crazy in my thinking that this is a no-brainer.