So wigs are considered medically necessary but hearing aids are not?

[DisneyFirefly]

I havent read all of the responses but...

What is medically necessary for one person migh tnot be considered medically necessary by someone else. Basically, if a doctor deems it medically necessary, it should be covered.

This is how I feel about this situation, having read through this whole thread. If the doctor says it's necessary, then the insurance company should cover at least 60% of it.

BCP should definitley be covered. IMO, it should be free as preventative care. But I get mine to help curb the symptoms of severity of PCOS. We've had issues with this as well.

And this is what I dealt with when I was eighteen. I was diagnosed with severe PCOS and my OBGYN told me that I had a 75% chance of it turning into ovarian cancer without treatment. She prescribed oral contraceptives, not for the prevention of pregnancy, but for hormone regulation to prevent further cysts from forming and to lower my risk of cancer. Yet, my then-insurance company wouldn't cover it. But they'd cover Viagra for erectile dysfunction (for the record, I have no problem with people using that medication for what it was originally made for). So they'd pay for a guy to be able to knock me up, but not for me to not only prevent getting knocked up, but reduce my chances of ovarian cancer.

As it turned out, I didn't get on BC until I was 23. Even then, it wasn't through a traditional insurance company. I found out that in Illinois, there's a state funded program for low-income women that provides free birth control, STD testing, annual pap smears, etc. You have to qualify for it, and I did. I was on the pill for about nine months before I moved to Florida, then got back on it in 2009 when I moved back to Illinois. I decided to change forms, though, because the oral pill wasn't working for me. I now have an implant that's good for three years. My current insurance still won't cover birth control, so it's a good thing I'm on the implant. I'm concerned about how I'm going to pay to have it removed in 2013, though. But again, they cover Viagra and Cialis, even just for ED use.

As for insurance not covering things that they should, well...

When my sister was 16, in 2002, she was run over by a CTA bus (public transit in Chicago). Because of the way she fell underneath it, her forearm was fractured, her elbow crushed, and her shoulder dislocated. Her arm looked like bloody cottage cheese, according to witnesses. She has metal parts in her arm and snake-like scar tissue from skin grafts. Our insurance only paid 40% of the bills and we couldn't afford the rest, since the bills totaled over $1m. My parents sued the CTA to cover the rest of the bills (it was entirely the driver's fault, and he later harassed my sister when he saw her on another bus, as he didn't even lose his job despite running over a 16 year old girl), and got it, with a little extra for my sister, since her mobility in her arm was reduced due to the accident. Even with all the physical therapy she went through, she still only has about 80% mobility in her left arm, which is a huge pain in the neck, since she's a tattoo artist. She tends to wear long sleeves to cover the scars, and was actually required to when she worked at a daycare while my niece was still a baby.

When my brother was 16, in 1997, he degloved his scalp going pier diving (dove off the end of a pier into Lake Michigan, without knowing what was under the surface). It was an accident, and the insurance again only paid 40%. We went without for a long time to pay off the rest of his surgery and hospital stay. He has a long ragged scar running from the end of his left eyebrow up over the top of his head and down to the nape of his neck. He's glad that he wears a hat at work because he gets questions about it all the time.

 

[fenrir58]

n/m

 

[bicker]

What is medically necessary for one person migh tnot be considered medically necessary by someone else. Basically, if a doctor deems it medically necessary, it should be covered.

Resulting in a much higher premium, that most of us couldn't afford. How is that better?

Basiclaly, it is the insurance companies. They released the amount that the companies actually SPEND on health care and some companies dont even spend 50% of the premiums paid on health care.

As many people know, I'm an investor. While it isn't really a bad investment, on the surface, I'd rather invest in pharmaceuticals or medical devices. Beyond that, many of the insurers are actually not-for-profits (which is a sign that the sector isn't really a good sector to invest in).

So, no, it isn't the insurance companies.

On the whole, private insurance companies suck

By your logic, life sucks (and, at least from certain vantage points, that's true), because most of the insinuations you made about the health insurance industry were off-the-mark.

 

[golfgal]

This is how I feel about this situation, having read through this whole thread. If the doctor says it's necessary, then the insurance company should cover at least 60% of it.



And this is what I dealt with when I was eighteen. I was diagnosed with severe PCOS and my OBGYN told me that I had a 75% chance of it turning into ovarian cancer without treatment. She prescribed oral contraceptives, not for the prevention of pregnancy, but for hormone regulation to prevent further cysts from forming and to lower my risk of cancer. Yet, my then-insurance company wouldn't cover it. But they'd cover Viagra for erectile dysfunction (for the record, I have no problem with people using that medication for what it was originally made for). So they'd pay for a guy to be able to knock me up, but not for me to not only prevent getting knocked up, but reduce my chances of ovarian cancer.

As it turned out, I didn't get on BC until I was 23. Even then, it wasn't through a traditional insurance company. I found out that in Illinois, there's a state funded program for low-income women that provides free birth control, STD testing, annual pap smears, etc. You have to qualify for it, and I did. I was on the pill for about nine months before I moved to Florida, then got back on it in 2009 when I moved back to Illinois. I decided to change forms, though, because the oral pill wasn't working for me. I now have an implant that's good for three years. My current insurance still won't cover birth control, so it's a good thing I'm on the implant. I'm concerned about how I'm going to pay to have it removed in 2013, though. But again, they cover Viagra and Cialis, even just for ED use.

As for insurance not covering things that they should, well...

When my sister was 16, in 2002, she was run over by a CTA bus (public transit in Chicago). Because of the way she fell underneath it, her forearm was fractured, her elbow crushed, and her shoulder dislocated. Her arm looked like bloody cottage cheese, according to witnesses. She has metal parts in her arm and snake-like scar tissue from skin grafts. Our insurance only paid 40% of the bills and we couldn't afford the rest, since the bills totaled over $1m. My parents sued the CTA to cover the rest of the bills (it was entirely the driver's fault, and he later harassed my sister when he saw her on another bus, as he didn't even lose his job despite running over a 16 year old girl), and got it, with a little extra for my sister, since her mobility in her arm was reduced due to the accident. Even with all the physical therapy she went through, she still only has about 80% mobility in her left arm, which is a huge pain in the neck, since she's a tattoo artist. She tends to wear long sleeves to cover the scars, and was actually required to when she worked at a daycare while my niece was still a baby.

When my brother was 16, in 1997, he degloved his scalp going pier diving (dove off the end of a pier into Lake Michigan, without knowing what was under the surface). It was an accident, and the insurance again only paid 40%. We went without for a long time to pay off the rest of his surgery and hospital stay. He has a long ragged scar running from the end of his left eyebrow up over the top of his head and down to the nape of his neck. He's glad that he wears a hat at work because he gets questions about it all the time.

Your issues are more from the POLICY you had, not your insurance company. Either treatment you sought was out of network or you had limited coverage. The bus accident should never have even gone to your personal insurance company, it all should have been taken care of through the bus company insurance. In the case of an accident involving any motorized vehicle, you should contact your AUTO insurance company and have them work on the claim for you. I am really surprised the hospital didn't start there.

People tend to forget quite easily that most companies are self insured and your EMPLOYER decides what coverage you have, NOT the insurance company. In my case with the hearing aids, NO company covers them so there isn't a choice. Some companies that are self-insured will opt to cover them but we have never had that coverage (DH's company is too small to self-insure).

 

[Pea-n-Me]

It is always about profits - and that's the way it is supposed to work.

My point was that it behooves insurers to approve therapies that improve medical outlook so that they don't have to pay out as much over the long haul. Or to increase profit, if you prefer. Better quality of life benefits everyone.

 

[golfgal]

I went to get my auto tabs renewed and the lady that works at the center is VERY soft spoken. I can't understand a WORD she says. She was saying something, I let her finish and asked her to repeat herself, leaning in as close as I could get so I could hear her, she ROLLED HER EYES at me and very disgustedly repeats what she said (she needed to see my driver's license with the check I was writing). I am so tired of crap like this from people--sorry, I can't listen harder

 

[mnrose]

My child wears Hearing Aids and this annoys me to no end.

I also noticed that Birth Control and Gastric Bypass is covered!

UGH!

It makes me soooo mad that Hearing Aids are not covered. I guess they go with eyeglasses and thus vision care. But I cannot get Hearing aid insurance like you can get Vision!

Another one annoyed by this. My son wears a hearing aid, and we had to pay for it. Thankfully, we could afford it. But, I'll never understand the logic. My son's hearing loss is due to nerve damage he suffered in utero.

 

[NotUrsula]

My ENT is a leader in the field; a very well-known expert who was one of the pioneers who helped perfect the clinical use of the Cochlear implant. He explained the reason to me very succinctly: too many people would qualify. He tells me that about 50% of the US population over 50 years of age has some degree of hearing loss, and by age 85, over 90% of that population can be described as clinically hearing-impaired. If they paid for any age-related hearing loss they would have to pay for it for every policy-holder, and essentially, everyone who did not die young from unusual causes would qualify for one eventually.

IME, most insurers will provide some coverage for aids for pediatric patients or for adult patients who experience traumatic complete hearing loss, but almost none of them will cover gradual hearing loss, which is exacerbated by age.

Insurance is a game of averages:you balance the risk of a covered condition occurring in a certain segment of the population (and having to be paid for) against the likelihood that it actually will. If a condition is virtually guaranteed to affect every member of a certain population eventually, then covering it is a losing proposition.

PS: As for service workers who are soft-spoken, just let them know immediately that you are hard-of-hearing. It really isn't kind letting them go through the entire speech out of misplaced politeness when you know that you will be asking them to repeat the entire thing. I carry printed cards that say "I am partially deaf, but I can read lips. Please speak slowly and clearly, and please make sure that I can see your mouth as you speak. Thank you." Sometimes I get a clerk who thinks she's Dory, but most of the time once they read that card on top of the document stack, they look up and demonstrate good patience. (FTR, the worst instances of impatience that I have to deal with come from my children. They constantly get huffy about how I'm "ignoring" them, even though they know that my hearing is impaired.)

 

[golfgal]

My ENT is a leader in the field; a very well-known expert who was one of the pioneers who helped perfect the clinical use of the Cochlear implant. He explained the reason to me very succinctly: too many people would qualify. He tells me that about 50% of the US population over 50 years of age has some degree of hearing loss, and by age 85, over 90% of that population can be described as clinically hearing-impaired. If they paid for any age-related hearing loss they would have to pay for it for every policy-holder, and essentially, everyone who did not die young from unusual causes would qualify for one eventually.

IME, most insurers will provide some coverage for aids for pediatric patients or for adult patients who experience traumatic complete hearing loss, but almost none of them will cover gradual hearing loss, which is exacerbated by age.

Insurance is a game of averages:you balance the risk of a covered condition occurring in a certain segment of the population (and having to be paid for) against the likelihood that it actually will. If a condition is virtually guaranteed to affect every member of a certain population eventually, then covering it is a losing proposition.

I have yet to come across an insurance policy that will cover hearing aids for anyone over the age of 18. We have had at least 10 different policies since I have lost my hearing (from changing company policies/changing companies) My loss was sudden (but not traumatic in the sense that it was from an injury to my ear) and certainly at age 29 was not age related. Over 50% of the population will have some chronic illness of some kind so by your ENT's logic, we shouldn't cover chronic illnesses either.

My ENT doesn't understand not getting hearing aids covered either and my ENT probably wrote the books your ENT used in medical school.

 

[NotUrsula]

I have yet to come across an insurance policy that will cover hearing aids for anyone over the age of 18. We have had at least 10 different policies since I have lost my hearing (from changing company policies/changing companies) My loss was sudden (but not traumatic in the sense that it was from an injury to my ear) and certainly at age 29 was not age related. Over 50% of the population will have some chronic illness of some kind so by your ENT's logic, we shouldn't cover chronic illnesses either.

My ENT doesn't understand not getting hearing aids covered either and my ENT probably wrote the books your ENT used in medical school.

Yes, but 50% of the population won't have the SAME chronic illness. Again, the insurance business is a gamble, and it doen't pay to bet against a sure thing.

FWIW, my MIL is a Federal retiree, and her insurance will pay up to $2000 every five years for aids for adults, regardless of the reason for the loss. She's 79 and just agreed to get aids this year; she got a check for $1600 just by having the ENT's office fill out the standard claim form.

My own insurance will pay up to $2500 every 3 years for aids needed because of sudden hearing loss caused by accidents or diseases unrelated to the ear, and almost all worker's comp policies will pay for aids for losses arising out of conditions of employment. The rule is that the condition must be diagnosed by a licensed physician and the aid must be prescribed by a licensed physician (not a technician.)

 

[golfgal]

Yes, but 50% of the population won't have the SAME chronic illness. Again, the insurance business is a gamble, and it doen't pay to bet against a sure thing.

FWIW, my MIL is a Federal retiree, and her insurance will pay up to $2000 every five years for aids for adults, regardless of the reason for the loss. She's 79 and just agreed to get aids this year; she got a check for $1600 just by having the ENT's office fill out the standard claim form.

My own insurance will pay up to $2500 every 3 years for aids needed because of sudden hearing loss caused by accidents or diseases unrelated to the ear, and almost all worker's comp policies will pay for aids for losses arising out of conditions of employment. The rule is that the condition must be diagnosed by a licensed physician and the aid must be prescribed by a licensed physician (not a technician.)

Consider yourself lucky if you ever need them because this is VERY RARE. Work comp isn't a health insurance policy.

 

[sbell111]

I havent read all of the responses but...

What is medically necessary for one person migh tnot be considered medically necessary by someone else. Basically, if a doctor deems it medically necessary, it should be covered.

I disagree.

When we buy insurance coverage, we basically are signing a contract stating that they will cover A, B, & C, but not X, Y, & Z. It doesn't matter if X, Y, & Z are medically necessary or not. They are not covered, nor should they be.

As it relates to this thread, wigs are covered and hearing aids aren't. If you wan't coverage for hearing aids, but not wigs, you need to negotiate a new policy.

 

[NotUrsula]

Consider yourself lucky if you ever need them because this is VERY RARE. Work comp isn't a health insurance policy.

Not to beat a dead horse, but I *do* need them. Why else would I have a regular ENT? (Well, actually, he's an oto-neurologist -- I just said ENT for simple shorthand and because most posters here don't know what an oto-neurologist is. My hearing loss is due to Ménières.)

And I know that worker's compensation isn't a health insurance policy; but the vast majority of people who have adult traumatic hearing loss have it happen in some work-related way, and in such cases comp claims normally cover aids.

 

[bicker]

My point was that it behooves insurers to approve therapies that improve medical outlook so that they don't have to pay out as much over the long haul. Or to increase profit, if you prefer.

I think there is a lot of different opinions about whether specific treatments directly improve the bottom line of the insurance company that covers those treatments.

 

[daughtersrus]

IME, most insurers will provide some coverage for aids for pediatric patients or for adult patients who experience traumatic complete hearing loss, but almost none of them will cover gradual hearing loss, which is exacerbated by age.

Our insurance covers $600 total every 4 years. That includes the aids, ear molds, audio testing...

DD's aids run about $5,000 alone. The cost of molds are over $100 a pair. Add in an ABR and your talking over $10,000 for that test alone. These out of pocket expenses do not go towards our deductible or our total out of pocket expense either.

It costs us tens of thousands of dollars to get DD set up with her first set of hearing aids when she was 1 yo between the tests that needed to be done and all of the doctors and hospital costs (anesthesia, OR, ENT...) plus the cost of the aids and molds.

I don't buy the idea that it's based on cost because the insurance told us that they would cover as much speech therapy as needed determined by DD's ENT but not the aids. The ENT told them that she would need ST every day and they said fine. The cost of ST at the time (this was 15 years ago) was over $200 for a 50 min session. What good is ST if the child can't hear what's being said!

 

[NotUrsula]

As I said, that's what I was told by my doc. He has a vested interest in getting aids covered by insurance because he holds patents on several implant models. (Not that I have implant aids, but implants are a big part of his practice, for both kids and adults.)

My own observation is that when you're dealing with the issue of pediatric aids, what you are dealing with is a negotiation issue on the employer's part, and a perception issue on the part of state governments. Deafness in children is still pretty rare as a percentage of the general child population, so employers often don't think there is a demand for this, and most people who have never dealt with purchasing aids have not got a CLUE about how much they cost. It also doesn't help that there is a popular perception that deaf people get along just fine by signing. (AND there is that whole deaf-culture movement to contend with, too.) If you live in a state that mandates coverage then you get it, and if you don't, then you pay for the fact that only 18 states mandate pediatric coverage -- the insurance companies will try their dangdest to avoid paying for them elsewhere so as to distribute the liability cost. I live in a border area between two states that differ on this, and what I've heard through the grapevine is that it is very common for families to move across the state line asap after getting a diagnosis. Wisconsin is mecca for the parents of deaf children in this regard: it's the only state that mandates coverage of implants.

In the end, these things tend to come down to what it important to the executives signing the policy contracts. I know that it's ridiculous to save money by denying coverage for birth control only to turn around and pay for Viagra, but follow the money. Insurance is one of those industries where contracts rise and fall on the way that business is channeled from one firm to another. If a device industry lobby pushes hard enough for a coverage mandate, then they sell a lot more of what they make, and if they don't, then, well, most of the time they don't.

 

[Mskanga]

I disagree.

When we buy insurance coverage, we basically are signing a contract stating that they will cover A, B, & C, but not X, Y, & Z. It doesn't matter if X, Y, & Z are medically necessary or not. They are not covered, nor should they be.

As it relates to this thread, wigs are covered and hearing aids aren't. If you wan't coverage for hearing aids, but not wigs, you need to negotiate a new policy.

That first part may have been in your case , I know in ours that was not the case , we were given a memo with very basic info and enrollment papers that we read in detail . The book of benefits did not arrive until weeks later with the insurance cards.

As for the second part , try to negotiate a new policy that is under an employer , see how that goes.

When we are dealing with an insurance company who is making well over 100 million profit in one year , they are not doing that bad......they should pay for what people need , not feed their own pockets.

 

[golfgal]

I disagree.

When we buy insurance coverage, we basically are signing a contract stating that they will cover A, B, & C, but not X, Y, & Z. It doesn't matter if X, Y, & Z are medically necessary or not. They are not covered, nor should they be.

As it relates to this thread, wigs are covered and hearing aids aren't. If you wan't coverage for hearing aids, but not wigs, you need to negotiate a new policy.

Since when do employees have any say in negotiating the insurance contracts, never?


Oh, another thing, in our state medical things are not taxed (prescriptions, glasses, etc.) except hearing aids-they are taxed

 

[bicker]

I suppose if the doctor worked for the insurance company that would make sense. Doctors are not fair arbiters. They advocate for themselves (CYA), for you, and for the drug companies and medical device companies that give them promotional compensation, so they have no reason to be fair to the insurers.

 

[Lisa loves Pooh]

Walk a mile in my shoes before you flippantly dismiss it as "feeling good about themselves". You have no idea what you are talking about, trust me.

My apologies for coming across a flippant. I certainly did not mean to insult or offend anyone.

My opinion about restoring function still stands given many of the reasons posted from all POV posted in thread. Restoring function is extremely important given the reasons wigs are approved for reasons that seem to allow hearing aids to be denied.

Other than that Bicker has posted quite useful.