Insurance Issues

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Permalink Reply by Kathleen Belisario on October 21, 2009 at 5:39pm

Anna, thank you. It's worth a try. I'm going broke buying sensors!

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Permalink Reply by Rickst29 on November 4, 2009 at 1:43pm

Jana, did you ever follow up and win this? I've not received a PM with your email address or a phone number. It's almost certainly winnable.

The ****FIRST**** which you need to do is check your dates with your MD's office-- in many contracts, you MUST submit a request for review or appeal within just sixty days after the initial PAR was denied. If you let that time period expire then your right to appeal is absolutely, totally, DEAD. The date which matters is the date on which they received the PAR denial.

BCBS of SC is a privately held company, it's not merely another DBA name of WellPoint. With WellPoint, people hardly ever even need my help anymore-- I've forced them to cover so many times that they'll often accept responsibility without even a single denial. When they do deny, their MD in charge of CGMS has seen variations of my "form letter" so many times that she immediately recognizes "....this person is working with Rick; cover it, we won't win." I fought with them just a few times, and now everyone else wins too.

But let me get back to your BCBS/SC. Of course the greedy, privately held company won't VOLUNTEER to work with anybody to provide costly, use-once DME equipment on an ongoing basis. At least once, they need to be forced to do it. So I'd **love to** work with you and establish the benefit at BCBS/SC.

The second thing to do is get a copies of the letter which they sent in reply to your MD's PMA, and a copy of the Prior Authorization Request (PAR) which your MD submitted to them. These are both in your medical record-- the originals stays in the office, but you can ask them to make copies for you. (Get the DATE on the denial letter before you let them mail these things, because mailing will lose another 3 days which you might be able to spare anymore.)

The denial is probably only one sentence long. But if they said "not medically necessary", that's WAY different from saying "I's experimental/investigative technology and/or not medically necessary".Most of the time, they'll say both-- throw as much mud as they can, and hope that some of it sticks to the wall. But legal battles are battles of words, and it's bad for your side to waste lots of words on something irrelevant to the reason(s) which they actually claimed.

Then PM me with both items: the exact wording they used, and the date they sent the denial. Or a phone number, and/or an email addr at which confidential things maybe received from me in reply. I've described, in other post to this Thread, why Heather and your MD cannot play hard-ball with your insurance company. You must do it yourself.

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Permalink Reply by Jana on November 4, 2009 at 2:27pm

Blue Choice is a subsidiary of BCBS. They didn't deny the coverage they just don't deal with Dexcom or any of the other companies that Dexcom deals with. They do deal with the Medtronic and said that I could get that, but I don't want that one. So, I am changing to BCBS of SC in January and I will just wait and get the Dexcom then. I have checked and they work with Dexcom.

Thanks for all of the info!!
j.

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Permalink Reply by Rickst29 on November 4, 2009 at 5:20pm

sounds good!

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