Sleeves and insurance

Journey

My INS said I must get a letter calling for medical necessity which my PCP wrote.

They claim they will pay (80%) for 3 sleeves per yr.

I know Bob works specifically with Medicare denials.  Does he also work with 3rd party insurers?  That's wonderful if he does.  Either way, Binney is right, Bob is a great resource.  If you recently became Medicare eligible, that could result in changes in coverage from secondary insurance. Medicare Supplemental insurance generally follows Medicare guidelines.  Secondary plans by 3rd party insurance will sometimes cover items that Medicare denies.  If your garments were covered under your employers health plan and then you go on COBRA due to retirement or changing jobs, COBRA must cover all claims the same as when you were an employee for the full time of your COBRA coverage period.

Did Humana give you a specific reason for the denial?  Especially since they covered your garments in the past?  If it is a coding error by your provider or insufficient documentation submitted by your provider, that could result in a denial.  Letters of Medical Necessity ARE required along with your specific lymphedema history from your medical record.  Your insurance must tell you why it was denied.  Start there and see where it leads you.

I recently changed DME providers because all of a sudden my garment claims were being denied for the first time in 6 years.  Turns out my provider was having major problems in their billing office and their documentation/coding submission was not meeting the insurance requirements, so the claims were automatically denied.  After switching to a new DME provider my insurance claims were approved without any problem.

The following is a brief step-by-step guide Bob posted regarding Medicare denials.  This should be helpful to anyone who has Medicare.

Medicare will deny claims for lymphedema bandages and garments, period. Most supplementary insurance policies will not cover an item if Medicare says it is not covered. In order to be reimbursed for your expenses for purchasing these items you must do the following:     

1. Obtain a prescription from a Medicare-enrolled physician.

2. Purchase the items from a Medicare-enrolled Supplier. You must pay up front. You will be asked to sign an Advance Benefit Notice of NonCoverage (ABN) form. The Medicare-enrolled Supplier must, by law, submit a claim to Medicare.      

3. You will receive a denial from Medicare on your next quarterly Medicare Summary Notice, with instructions on how to appeal that denial. The reason that will be given is that "This service is not covered by Medicare" or "This item does not meet the coverage requirements in the LCD for Surgical Dressings".

4 Upon receiving the denial, contact me and I will help you through the next few appeal steps, and will file for you if you so desire. But you must follow steps 1. and 2. in order for me to help.    

Robert Weiss, M.S.

Lymphedema Patient Advocate

Lymphactivist@aol.com

LOOPHOLE?

I believe the wording in  the act should change. I really don't care for :

"This act requires these health plans to provide coverage for reconstructive surgery and related services that may follow a mastectomy.

How about ...' that may follow breast cancer treatment."

It may end up being more than a matter of semantics, but rather, grounds for denial.

I could really see some snags with that .  In any case, my ins . will cover to a point anything ordered by a  DR that is deemed MED. NECESSARY.

I did note that on my OT/PT approval letter they specifically mentioned ' massage therapy' was not covered. I will be sure to bring this to the LE therapist attaention and be certain she words things correctly, with goals such as

"channeling the lymphatic drainage to alternate pathways ' and possibly improving cirulation and lymphatic function,  demonstrating proper skin care and prevention of cellulitis etc, teaching patient care for disease mgmnt. ...etc...

MLD  may look more like ' massage' if not worded just right.

We have to be our own advocates, ESP. with  any new gov't changes which may occur with universal.

I am not sure, maybe someone can help me. I thought I saw a link to the law regarding LE sleeves. I thought that insurances had to cover them, but NOT medicare. I remember thinking what a bunch of crap. Other insurances cover them, but the law makers made an exception for Medicare.

What ???!

No no no crystal....this is wrong!  Keep pursuing under DME with your ins co.

Crystal,

Like Tina referenced the government website with the document, as I did on my post above, please keep fighting this.  Please see my post above.  UHC tried to pull the same stuff on me, but because I knew I had read somewhere on these boards that they are required to cover because of the Act, I referenced that Act to the insurance company and that pretty much left them with nothing to negotiate.  And...since then, they have never denied me coverage and I get off the shelf garments as well as custom made.  Maybe the wording on the prescription is throwing a glich in the system?  My doctor must always reference my breast cancer diagnosis on each prescription and then write that it is needed for lymphedema.  Possibly this might be causing some trouble? 

Please keep pursuing...if I hadn't referenced the Act to the insurance company, they likely would never have paid for them.  It is all about making and saving money for them and unfortunately, we are forced to be a smart consumer.  It is just ridiculous that we have to be arguing after all we have been through.

Be well. 

Tina337: re the law that u referenced above, are the companies able to limit the number of garments? Coventry tells me only two arm compression per year, tough because I need for both arms....also denied night sleeve since they approved the Flexitouch. I need both and a chest compression garment for the night other than the compression bra for truncal lymphedema. I find very interesting that the insurance company feels that they know what I need as compared to what the Dr. Ordered! Thanks for any tips anyone has. I am considering writing an appeal to Coventry.

Tina337: I see my therapist twice weekly, do mld,use the daytime sleeves, compression bra and the Flexitouch! That is why I am surprised that the insurance company gets to decide that I would not benefit from the nightime compression garment. I may end up having to wait until the first of Jan. and self purchase to count towards my deductible. The DME company is about that slow anyway. The therapist is in hope the nightie sleeve and truncal compression will keep the swelling down at a more manageable level. I can agree with what I see frequently on these posts, lymphedema is not fun! Thanks for your post.

Tina, the speaker you are remembering is Dr. Joseph Feldman, who has a lymphology medical practice in Chicago, and is the chairman of LANA, which administers a test and grants the CLT-LANA credential.  I remember that he said that in his view, pumps should be used when conventional treatments fail or when a patient is unable to perform MLD, i.e. someone with a disability, or bilateral arm LE where hand issues make it difficult to perform MLD on the opposite hand/arm.

Carol, yes, he was not a fan of the pump at all and thought they should be used as a last resort. It is nuts that insurance co's will pay for such an expensive machine and then argue over covering a night garment. Do you remember the percentage of pumps that end up unused and sit in the back of a closet? It was some crazy number.

This is a wonderful thing Purple...but it adds to my confusion because it directly says medicare does not cover the sleeves.

I have no idea why this is all so confusing....

But I am so thankful for all of your posts and information everyone!!!!!

Bob would seem a good resource.  Given that the "elderly" are the most prone to BC and the nasty side effects of treatment, it would seem that Medicare would want to address the issues in its earliest stages, before it becomes more expensive to treat.  I do find it interesting that Medicare will approve treatment in the later stages when quality of life is most affected.  I am helping to pass the word on Medicare's non coverge of compression garments.  I was able to get them with no problem until I went on Medicare.  Now sip, I may have to use Bob myself!  The following gives information and the site of the Lymphedema Treatment Act.  it amazes me how many health care professionals are unaware that compression garments are not covered by Medicare

Are you aware that Medicare does not cover compression garments for breast cancer patients with lymphedema?  Most healthcare providers are not.  As the majority of women who contract BC are older, this is a serious issue for those who endure lymph node surgery and as a result have their lymph system compromised and suffer from lymphedma. This includes 20 to 30% of women who have endured surgery for BC. If you are on Medicare this simple inexpensive method of control is not covered and must go on to more serious issues before treatment is covered. Currently there is a measure before congress to change this situation, not only for those with Medicare, but also those with primary lymphedema who do not have their needs covered.  Your support of the Lymphedema Treatment Act would be most appreciated.  More information can be obtained at the following website.
www.LymphedemaTreatmentAct.org
Thank you for your time and consideration in this matter.

My health insurance covers the sleeves as Durable Medical Equipment at 80-20 in network. Unfortunately they don't have any vendors in network that carry my particular sleeve (Sigvaris 500) so I would have to go to 50-50 out of network with a $400 deductible. In other words, cheaper to buy them out of pocket and not have to put through all the paperwork it entails for virtually no reimbursement 

Hi Laural,

That is why it is so important that we oldies but goodies (on Medicare) check out

www.LymphedemaTreatmentAct.org and get involved in any way we can to get this Act through Congress.  I was fine re compression garments until I went kicking and screaming on Medicare.  As far as I am concerned this is discrimination against those who are most likely to be affected by breast cancer and its after effects!  Through the above site you can get in touch with your representatives and let them know why this legislation is so important.  It is a shame that Medicare covers lymphedema only after it has progressed to a more serious and expensive state.  This is penny wise and pound foolish. 

Take care