Insurance coverage for class 1 (20- 30 mm Hg) compression?

KS1

Insurance coverage for class 1 (20- 30 mm Hg) compression?

KS1

I wear 20-30 mm Hg compression garments. My DME company just told me that BC/BS is demanding a letter of medical necessity (and not just an RX like in the past) for compression garments that are < 30 mm Hg. The DME company said that BC/BS is now arguing that < 30 mm Hg is not "medically necessary or therapeutic" and so the letter has to say specifically say why I need lower compression (and not 30-40 mm Hg). My understanding is that 20-30 (i.e., class I) was very commonly used for upper extremity LE and was considered "therapeutic".

Has anyone had a similar experience recently? I'm sure I can get a letter from the doctor who I have seen in the past for LE, but it's going to be months before I can get an appointment.

Does anyone know of any articles that say that class 1 is appropriate for (at least some cases) of LE. I could probably convince my PCP to sign a letter for me, but I am going to have to draft it, and I'm going to have to cite studies.

KS1

carol57

KS1, this is crazy. I googled for a minute and found Aetna's policy regarding LE treatment, including compression, and there's no distinction between classes. I'm saddened to hear that our already-skimpy LE coverage might become even poorer. Reading the Aetna policy is not encouraging, and you're seeing even more exclusions develop. Ugh. Here's a link to the Aetna policy, which does cite some studies, although none that I can readily identify showing compression class distinctions.

http://www.aetna.com/cpb/medical/data/1_99/0069.html

carol57

KS1, here's another page from Aetna's policy that specifically discusses compression:

http://www.aetna.com/cpb/medical/data/400_499/0482.html

vlnrph

Unbelievable. I recently appealed an MRI denial with success so insurance companies are known to reverse themselves. I'm still waiting for the written confirmation but will quote my good friend the "grievance analyst" if they try to delay payment...

You're right in thinking that citing studies is good - wish we had the level of research going on in LE that other conditions seem to have. It's possible your doctor's office has already dealt with other similar cases which means they may have a template for a response letter on hand.

Many people would just give up and pay out of pocket, saving the company money (which is what they plan/hope for, I'm sure). These things are expensive enough that I say fight for your benefits and let us know how it turns out.

RosesToeses

Oh man! I have BC/BS, too, and I wonder how it's going to go for me the next time I'm due to replace the sleeves and gloves

Wishing you luck, but I also wanted to say, you mentioned having to wait for an appointment before you could get your letter--my experience is if the doctor has already seen you for the condition, it's usually no problem to call and leave a message with what you need and they will usually either leave it at the desk for you to pick up or fax it to you.

Good luck!

Binney4

KS, that's a new one to me, and let's hope it's not the wave of the future. Aaugh!

Have you contacted the Lymph Activist, Bob Weiss? He's always willing to help lymphers with their insurance battles and will no doubt have some suggestions about how best to document the need for 20-30 compression. He works for us all on behalf of the National Lymphedema Network, and there's no charge for his help. His email is:

LymphActivist (at) aol (dot) com

Hope that helps. I'll keep looking for documentation that might help. I do know that everything you gather should be faxed to the insurance company from your doctor, because they're obliged to read whatever comes from a doctor--from us, no so much.

Keep us posted, please!

Binney

PersonalTrainer

My claim for sleeves was at first denied by Aetna as not being medically necessary. This after being told my many representatives at Aetna that they were covered and there was no problem. The DME company had even called twice to check benefits. It took them months of holding the claim - but they denied both my sleeves and my night sleeve. This after approving a FlexiTouch for me in three days.

Anyway - I never could get a good answer as to why they were denied. I do know they asked for clinical notes from my OT. Swelling in my arm has never been my primary problem - my arm will swell, but it's not that big - and when it gets treatment, it's small. It's my shoulder and side that are the issue.

I ended up appealing. I sent them a letter - long - detailing my problems with lymphedema, several studies, and a letter of medical necessity from my oncologist. It your doctor has seen you for lymphedema in the past, a call to his/her office should be enough to get a letter for you.

I did win.

One thing I learned: I no longer deal with the insurance company over the phone. I only ask questions in the form of e-mails through their website.

Make sure you get the letter and then if they deny you, appeal. It's wrong - they know it, but they want you to give up and not get treatment.

Binney4

KS, a dear friend and fellow LE advocate who has been following this thread just reminded me that you need to include a copy of the Women's Health and Cancer Rights Act of 1998, which mandates provision for LE specifically. You can include just the pertinent paragraph, but I always send the whole thing along (faxed from my doctor's office), as I think they need the full reminder of what it is they're toying with--YOU!!! Once they know you'll stop at nothing they'll give up and play nice. (For one of my appeals I showed up at their office with my DH and two kids, several books and a picnic lunch and told them we'd wait for their answer. Which they magically gave us within 20 minutes. Hmmmm…….)

Another thought you might pursue is to check that your request for coverage was coded correctly. Sometimes that makes all the difference.

Go get 'em!

Binney

Kicks

I don't deal with insurances - my care is through VA so my LE guy orders for me amd they come in.

Don't know where you would find info on it but our bodies are each unique and we react differently to different things.  For me, high compression only makes my LE BAD.  When I first started using garmemts, my LE guy ordered me a high compression set but within a 1/2 hr my hand had doubled in size so I get low compression amd it works great.  I'm also built 'weird' so 'off the shelf' do not fit me so have to have custom.  My hands are slightly webbed so standard gloves are not an option at all amd arms are longer than usual for 'size' (legs are very long also) - so I'm a 'knuckle dragger .

Kicks

Get a statement from your CLET as to why he\she has you using the compression level you do.

KittyDog

Our AETNA sucks. DMV deductible $2500. So you might as well say that don't cover anything. No Bras, No foobs, and no compression.

teacher911

Dear KS1, I have BC/BS Excellus and have had no problem with them covering my sleeve and 2 gauntlets. I also was determined to be class 1, my therapist filed all the paper work and my sleeve is from Jobst. I hope this is more a problem with coding. They are now currently working on getting a vest garment covered under insurance because I am not having great success moving the truncal lymphedema. I hope this resolves quickly for you.

carol57

Something frustrating about insurance is that just having a plan under BCBS or Aetna or United or whomever doesn't mean benefits are the same as under other plans with the same health insurance company. Individual plan coverages vary from state to state and from plan to plan with each state. So it's good that we report in what we're experiencing, because we can notice trends, but it's hard to compare our individual coverage experiences because our plans are most likely quite different. Except Medicare and Medicaid, which I believe are indeed standard everywhere.

KS1

SUCCESS. I talked again to the DME rep again, pointing out that class 1 was standard for upper extremity breast-cancer related lymphedema and compression garments are covered under the women's health act. She talked to BC/BS again and they are not going to require a letter for class 1 compression for upper extremity BC-related LE. I had a similar experience when I first started wearing garments. BC/BS initially denied the garments until I pointed out the diagnosis code was BC-related LE, and that it had to therefore be covered the same way other DME equipment is covered. KS1

PS BC/BS now requires letter for class 1 lower limb garments. It wasn't clear whether they now require letters for class 1 upper limb garments for non-BC related LE.

carol57

Hooray!! When we have our Winter Olymphics in a few months, you will surely win the hoop-jumping competition!! With extra style points for your calm and logical approach when you must have been steaming inside!