NIGHT sleeves and INS

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purple32
purple32 Member Posts: 3,188
edited June 2014 in Lymphedema

Hi Ladies

Someoine nearby  is in great need of  anew night sleeve.  Her dr. sent in the usual letter of medical necessity.

She just emailed this to me :

Just FYI  BC/BS has set a maximum dollar amount of $216.50 for reimbursement for garments.  And they will not pay for any garments with compression less than 30mg.  My garment fitter tells me that 90% of her business is below that threshold.  And my Reid Sleeve which was billed at over $2,000 three years ago is completely out of the question as far as BC/BS is concerned.  And if this is the new policy for BC/BS other companies may follow suit.  At least both my off the shelf garments and my custom garment are still covered. 

I'm currently investigating whether the company could possible alter my Reid Sleeve and make the thigh portion smaller and replace some straps etc.  Much like an old car that I want to keep on the road.  Baring that I guess I could file an appeal with BC/BS. 

If you have any suggestions, let me know.
==================================

I am clueless on the NIGHT SLEEVE aspect of all this ... any ideas at all ?
THX

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Comments

  • Binney4
    Binney4 Member Posts: 8,609
    edited May 2013

    She needs to contact Bob Weiss, the Lymphedema Activist for the NLN. His email is LymphActivist (at) aol (dot) com. He will be able to advise her and he'll advocate for her with her review board if necessary--if she's willing to follow through on an appeal it will help all of us. Bob's really knowledgeable about this and very accessible.

    Wishing her good luck and great new night garment!Kiss
    Binney

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  • carol57
    carol57 Member Posts: 3,567
    edited May 2013

    Purple, I was just on the Peninsula Medical website looking for a contact number for Spookiesmom, and I noticed this on their Q&A page:

     (eNews - 01/2013) My name is Julie and you may use my name. I have a current ReidSleeve Classic that I have had for a little over 5-years. I was told by my therapist about your refurbishment program. Can you tell me a little more? My ReidSleeve looks surprisingly good after 5-years, and it's still working for me great, but I think it should be evaluated. Thanks in advance, Julie

    Dear Julie!,

    Our Classic refurbishment program we offer will return your sleeve to new-like condition for a fraction of the cost of a new one. We also will evaluate your sleeve at no charge or obligation and we are happy to see if your insurance will cover the costs as many patients are surprised to find that refurbishment is a covered benefit. Please call me toll free to discuss the process in more specific detail. 1-800-29-EDEMA.

    ----

    So Purple, maybe this is an alternate approach for your friend, while she also pursues getting a better answer from her insurance company.  By the way, there is no 'one' BCBS plan, because employers have a large say in what's covered and what's not.  So we can't generalize.  Bob Weiss is one amazing, giving person who is THE go-to person for all questions about LE and insurance.

    Carol

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  • purple32
    purple32 Member Posts: 3,188
    edited May 2013

    By the way, there is no 'one' BCBS plan

    Oh yes, I know...this was  just my cut and copy of what she wrote me.

    Many thanks to both you and Binney,  Carol.  I will give her this info and hope that it helps- will keep you informed.

    THX!
    EDITED TO ADD:  Just want to say to you both :  I  just called her and read your posts to her. She was STUNNED at the support.  This gal has ben living with primary LE for yrs and says she is grateful for the support alone/ thanks again.  I'll let you know!

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  • purple32
    purple32 Member Posts: 3,188
    edited May 2013

    Hi Ladies

    I just wanted to write  a follow up.  Looks like this gal is getting helped.  She wrote an email to her/my  LEist and a fitter and included me in the cc.  I took an excerpt of her email  and decided to print it here for two reasons:

    To thank you both and as a follow up,

    Also, just in case, these codes/info should ever serve to help anyone else:


    " ... I talked to a wonderful woman at the corporate headquarters of Peninsula Medical named Shameisa. 1 800 293-3362.

    They do not use the A6549 code for billing for the Reid Sleeve. They use the miscellaneous code for Durable Medical Equipment. E1399. There is no set allowable under this code.

    She also described to me their refurbishment program which takes the whole thing apart - washes it, it gets new straps and it can be altered to fit the smaller thigh. The code for that is K0739. It also needs to be made longer to give me compression at the top of my thigh. The cost is $614.04.

    Kelly is the director of Customer Service. What they usually do is to compare costs between refurbishment and ordering a new one. I would really like to send them my current sleeve and have them evaluate it for me...."

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  • carol57
    carol57 Member Posts: 3,567
    edited May 2013

    Purple, that does sound like progress.  Wish her well from me!

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  • purple32
    purple32 Member Posts: 3,188
    edited May 2013

    Will do, Carol.  Thanks again for your help!

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