insurance appeal

Dot, I'll ask Binney to comment--she's worked with the Flexitouch reps.

In my experience, working for an insurance company, you need to prove medical necessity--that you have lymphedema that can not be controlled without the use of the flexi, you also have to prove that only the flexitouch will do--and they all write their benefits to exclude it, yet it's been studied in the medical literature and it clearly is superior--doesn't push fluid where it doesn't belong--the company should be able to get you articles to support "why the flexitouch"--not some cheaper model, and if you have medical records to support your need--any complications of lymphedema or mobility issues why you can't do MLD, and LE therapist records to document that your LE can not be controlled without the flexitouch.

And, when in doubt, threaten to go to the press about how you're being denied a medical device that is essential to maintaining your health, and one ER visit or hospital stay for cellulitis would be equal to the cost.

I always wonder if the National Lymphedema Network does advocacy--I know Bob Weiss, who is on this board as lymphactivist does appeals and could provide advice. He hasn't logged in for a year, but might respond to a pm-if not, pm me for his email

http://community.breastcancer.org/member/75363/profile

Stanley Rockson MD of Stanford did a lot of research on the flexitouch, and currently has a clinical trial comparing the flexi vs. compression sleeves in women who show high risk status for LE, for prevention

http://med.stanford.edu/profiles/Stanley_Rockson/

Here's a study that showed that people with LE benefited from the flexi

http://www.ncbi.nlm.nih.gov/pubmed/18591171

and another

http://www.ncbi.nlm.nih.gov/pubmed/20184680

This one shows that the older Lymphapress pump created higher pressures than the flexi (not good)

http://www.ncbi.nlm.nih.gov/pubmed/17712034

Good luck--and ask the Flexitouch company to help you as much as possible.

Here's their insurance link--if the local rep isn't helping, call the company

http://www.tactilesystems.com/flexitouch/healthcare.html

Kira

Thanks!

Also, get a copy of the benefit guidelines: I've seen the Cigna and Aetna ones, and they write about how good the flexitouch is, and that they will NOT cover it.

I couldn't find your plan's policy, but I did find the bcbs of nc:

Lymphedema pumps/sequential pneumatic compression devices are eligible for initial coverage when
ALL of the following criteria are met:
1. Confirmed diagnosis of primary or secondary lymphedema; and
2. Lymphedema is associated with functional impairment e.g., impairment of activities of daily living; and
3. When there is failure of a four-week trial of conservative medical therapies, (examples include eleva-
tion of the affected limb, exercise, massage, use of an appropriate compression bandage system or
compression garment); and
4. The patient has demonstrated compliance with past recommended medical treatment(s).
Continued use of lymphedema pumps/sequential pneumatic compression devices are considered eligible
for coverage when there is documented effectiveness of the pump, with a decrease in edema as docu-
mented by pre- and post-treatment measurements and/or documented improvement in functional capacity.
Pneumatic compression devices are covered as a treatment of last resort; for example, other more con-
servative treatments must have been tried first and found to be inadequate. Such treatments would include
leg or arm elevation and custom fabricated gradient pressure stockings or sleeves.
A segmented pneumatic compression device with manual control of the pressure in each chamber (HCPCS
code E0652) is considered medically necessary only when the patient has unique characteristics that prevent
them from receiving satisfactory pneumatic compression treatment using a nonsegmented device with a
segmented appliance/sleeve or a segmented compression device without manual control of pressure in each
chamber. Such conditions include significant scarring, sensitive skin or the presence of contracture with
documentation of the need for a specified pressure to a localized area. In addition, the criteria above must be
met.

Here's the link:

http://www.bcbsnc.com/assets/services/public/pdfs/medicalpolicy/lymphedema_pumps_sequential_pneumatic_compression_device.pdf

Good luck, and hope you get what you need--when in doubt, threaten to make it public.

Kira

Hi Dotty,

I am very interested in hearing what the board of appeals says as I also have had problems with BCBS of NJ. They have paid every penny of my cancer treatment, but have denied about 80% of my garment claims. Also, they have been inconsistent about therapy requests. My greatest inter-limb difference is less than the magical 2 cm mark, and my upper arm measurements have stayed constant (+/- .5 cm) over the past 18 months. But I think I have clinical signs of worsening LE - the skin above my elbow has become thicker, the definition of the muscles is greatly diminished, and my upper arm aches. (My guess is that muscle mass has been replaced by LE fluid.) I bet that if I wrapped, the upper arm would reduce and the ache subside. Alas, I was never taught to wrap and because my measurements are stable and I don't hit the 2 cm mark, insurance has denied LE Tx.   BCBS has also denied PT, despite documented brachial plexus neuropathy (by EMG and NCS) because I have near normal range of motion and strength. That's true, but my arm is much weaker than it used to be (I used to run 5Ks on Canadian crutches) and I have scapular winging. With the snow and ice, I really should be using a cane, but my LE/BPN arm is too weak. What I can't figure out is the inconsistency of BCBS.  Why do they cover garments some times, but not others despite the diagnosis code being the same?  And why did they deny arm PT, but approve OT for hand rehab?   KS1  

KS1--I think Horizon Blue Cross is a for profit? They tend to have the toughest benefits IMO.

When the AHQR did a literature review for LE, they looked at a lot of literature, and concluded that the 2 cm rule was the 'accepted gold standard"--but it was created by 2 PT's for one study. So, just because it's easy, doesn't mean it's a gold standard of anything.

Here's a link the AHQR and there are also comments, where many people commented that the 2 cm rule is not a universal standard

http://www.cms.gov/medicare-coverage-database/details/technology-assessments-details.aspx?TAId=66&bc=BAAgAAAAAAAA&

Unfortunately, after a literature review and hearings, they reached no real conclusions and would not address the lack of medicare and private insurance funding, but if you have the time and patience to sort through their literature review, you might find something to support your need for services. 

The lack of coverage for LE treatment is appalling.

Kira

Good luck to you - I have the flexitouch and I really love it.  I use it at least 5 times a week and while it doesn't take the place of MLD, it does really, really help.  I can really tell a difference when I don't use it.

Insurance is definitely a long uphill battle for most of us.  I may have witnessed a slim glimmer of hope though at our last months LE Support group meeting.  We had a new member with primary LE of both legs who just got 100% coverage of her new Flexitouch through her insurance (she's not medicare eligible yet)  She said the Flexitouch reps negotiated directly with her insurance...I believe she said it was BC/BS here in the Midwest but I will have to verify that at the next meeting if she is there.  She has never had any other pumps before so maybe they are starting to relax their criteria or recognize it will cost them less to go directly to the most effective device first.  The pump was being delivered at end of the week. 

P.S. The local Flexitouch rep attends our LE support group meetings on a regular basis, not overtly to sell their product but to understand what LE patients have to go through and to answer any questions that arise about their system. The have been very lowkey and unobtrusive when it comes to marketing, but seem genuinely interested in being involved with the LE community.

I was approved for and covered at 100% for an Optimal LE Pump and full jacket (both sleeves and trunc) through an out of network carrier...I honestly did not think it was going to be approved since my swelling is 'barely' visible although extremely painful.  My insurance was United Healthcare in AZ. 

On the other hand I could not find anyone in my area or within 120 mile radius that was able to fit me AND bill the insurance for my garments.  It is a nightmare trying to find what sleeve works for you when you do not have a local office in the area that can help you.  It got very expensive taking a day off work to drive 120 miles to get fitted for something only to discover by the time you got home that the sleeve/garment did not fit right

Dotty--your inability to do MLD due to arthritis is VERY important in this appeal: you physically are unable to perform a key component of home care self management. Get it in writing from an MD.

Hoping this goes through.

Kira

Dot, that's outrageous that you have to miss work: I guess Horizon is nonprofit, but pays its CEO over 8 million/year: their executive pay would provide a whole lot of health care...

http://www.nj.com/news/index.ssf/2010/06/nj_senator_proposes_imosing_pa.html

Kira

Dot, this totally sucks. Can you go public with a news article? If you're up to it. I know our insurance commissioner in our state--I worked for him for a bit and sent him an email about the low reimbursement for LE supplies and heard nothing.

But, I don't want to see you getting hurt from an inadequate pump--I'd suggest the State and ask Bob Weiss for help.

Insurancxe companies hate bad publicity--˙the one I worked for caved when a lawyer showed up to argue a denial.

Kira