Posted on: Tue, Jul 8 2008 5:52 PM
Posted by: Whitney
Posts: 692
Ok, since their reply was what I expected, its now time for you to prove to them that the payment for this is in your upmost health interest. I would first start by writing a formal letter directed to the case management department/appeals department of your insurance company. I would call first and ask where a such a letter would be directed to. Also, please make sure to not only put in the address field of the letter but the envelope Attn: Appeals - gets it there 9 times faster than if it got stuck in general intake. Explain in your letter the reason you feel that a standing frame would improve your health or be a necessity to your healthcare. I would also obtain an invoice from the DME provider that you will be purchasing the frame from and specifically tell them that it needs to include the HCPC code (or in insider-speak - hick-pick code) on the invoice. Include a copy of that with the letter as well as a letter from your doctor explaining his medical necessity reason as well as any supporting documentation, such as clinical trials, medical journal articles and any part of your medical file that would be appropriate to prove that this frame would greatly improve your quality of life.
If it gets denied again after all that, then I would get the case manager on the phone and conference call with the doctor. You have several appeal levels and the desicion doesn't usually stay with the same individual once you've requested additional appeals. Usually the process goes, a claims processor or intake coordinator in the case management does the initial denial based on a set list of HCPC codes. These folks are only doing what they're told to do and don't generally have any decision making power. Then it goes to a case manager, usually an RN, and then to her supervisor, also usually an RN, and then if things get really down and dirty it ends up in the lap of the Medical Director, who is an MD but of random specialty, usually internal medicine or ortheopedia.
The squeaky wheel usually gets the grease and so if you persist, you might be able to get them to pay for it. I'm never going to guaruntee anything, though.
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