Insurance Problem

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PersonalTrainer
PersonalTrainer Member Posts: 21
edited June 2014 in Lymphedema

Ugh - I'm having a problem again with coverage being denied for my compression garments.  Two years ago, the insurance I had through my husband's work decided sleeves weren't medically necessary for me after I was diagnosed with LE and the supplier had verified my coverage not once, but twice.  The only thing we could figure out was that since the LE began in my trunk and had just barely progressed to my arm at that point - they were denying based on the limited swelling in my arm.  I appealed and won.  

This year, my husband's company decided spouses will no longer be covered.  I had to pick up insurance through my work - which also means picking up more hours, which I was fortunately able to do - but I am now working a lot.  Before I enrolled in the health plan, the broker's office used the CPT codes my sleeves and Tribute garment had been billed with to check coverage for me.  All was to be covered.  

Two weeks ago, I asked through Anthem's website if I needed to preauthorize my sleeves, gloves and gauntlets.  The answer came back as follows: "Under your policy, compression garments are contractually excluded from your policy.  Contractually excluded services are not eligible for reimbursement by Anthem Blue Cross and Blue Shield."

I have gotten nowhere by calling and e-mailing them - they just say our contract doesn't cover any compression codes.  I can't even get a case manager to call me - they are now totally ignoring me - hoping I'll go away no doubt.  I, on the other hand, can find no reason they don't have to abide by the Woman's Cancer Act.  I have reported them to my State Insurance Commission.  The person assigned to my complaint called me Monday.  She was very nice and we spent a good deal of time on the phone because she was unaware of the Woman's Cancer Act.  So - of course now I'm more worried.  

Anyway - I am also contemplating  writing to the Departments of Labor and Health and Human Services, which oversee this law.  My thought is that if I am experiencing this treatment, others are as well. 

So, my question is - how many of you have had your coverage denied for compression by health plans which should be obligated to provide them under this law?

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  • carol57
    carol57 Member Posts: 3,567
    edited March 2014

    Personaltrainer, you might email Bob Weiss, lymphactivist (at) aol (dot) com.   Also check his website, www.lymphactivist.org  Bob has made a non-paid career out of understanding LE coverage and especially contesting the lack thereof.  He has helped several women in this forum, coaching them and in some cases actually working alongside them as they contested coverage denials.  He can give you a lot of background and help you craft your strategy.  He's a wonderful person and will welcome your inquiry.

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  • PersonalTrainer
    PersonalTrainer Member Posts: 21
    edited March 2014

    Thank you Carol.  I contacted Bob back almost 2 years ago when my first insurance company denied my coverage.  He sent me a lot of good material.  

    I'm just so frustrated.  The wording in the Woman's Health and Cancer Rights Act is very clear as to what benefits must cover.  It states:

    "Any physical complications at all stages of mastectomy, including lymphedema ([lim-fuh-DEE-muh] fluid build-up in the arm and chest on the side of the surgery)"

    And as we (saddly) know, what is the treatment for lymphedema?  Compression!  

    We know Medicare is exempt from this act - which is a huge issue - but how are private insurance companies getting away with denying this coverage?  

    I can't afford to pay out of pocket for my sleeves.  I'm looking at getting ready-to-wear ones just to have something to replace mine as they are getting old, but my custom sleeves are almost an inch longer than the long sizes of ready to wear.  And, my arm is a little smaller than the small everywhere except in the bicep.  

    I really do have to fight this.  We should not have to be having this fight all the time. 

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  • carol57
    carol57 Member Posts: 3,567
    edited March 2014

    No, you sure should not have to fight this, and none of us should have to argue for coverage.  Maybe Bob can help you again, this round. Yikes, sounds like a prize fight.  Actually, getting proper coverage does sometimes feel like duking it out in the ring, doesn't it?

    Hugz, if you're seeing this, I think I just came up with a new event for our summer oLYMPHics.

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  • PersonalTrainer
    PersonalTrainer Member Posts: 21
    edited March 2014

    Thanks Carol.  Yes - it is just like a fight.  Just received the letter in the mail from Anthem which was supposed to explain that they didn't cover compression.  Instead it's just double-talk about the durable medical benefit.  In fact, reading it, you'd think they actually covered everything.  There's no mention of compression garments or lymphedema even. Horrible company.  

    Ugh - and of course my arm aches today to top it all off.

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  • carol57
    carol57 Member Posts: 3,567
    edited March 2014

    PersonalTrainer, I am so, so sorry to hear this.  I hope you can muster the energy to keep pushing back.

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  • vlnrph
    vlnrph Member Posts: 1,632
    edited March 2014

    Don't give up - I have also experienced problems with this company. Even after prior auth was given, they refused to pay for my Flexitouch pump! The manufacturer Tactile Systems is fighting that one for me. I got an MRI approved upon appeal but the hospital still has not been paid. Every plan is different of course but certainly garments should be covered, at least partially.

    Good that you went to your state insurance commissioner. There seems to be a corporate attitude that denial of benefits is the best way for them to avoid responsibility. Their website and grievance process is not very efficient in fostering communication. Hang in there and let us know how it goes.

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  • PersonalTrainer
    PersonalTrainer Member Posts: 21
    edited March 2014

    Thank you.  I just sent an e-mail to the person at the State assigned to my case because I haven't heard from her in a week.  I will not give up on this.  It's not right - and if they do this to me, they will do this to as many people as they can get away with.  We have the fight to get the Lymphedema Treatment Act in place to make sure these garments are covered by Medicare and Medicaid, but a law is only as good as its enforcement.  If insurance companies feel they can so blatantly ignore the Woman's Health and Cancer Rights Act, what good is the law?

     

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  • bhd1
    bhd1 Member Posts: 3,874
    edited March 2014

    squeeiy wheel

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  • SpecialK
    SpecialK Member Posts: 16,486
    edited March 2014

    The supplier of my sleeves/gauntlets initially told me that my particular insurance company (military) did not cover garments for lymphedema.  This is a large prosthetic company with an in-house insurance department.  I paid for them (bi-lat, so two sets) out of pocket, but could not figure out why my insurance would pay for physical therapy with a certified LE PT, but not cover garments.  It also confused me that garments for the lower body seemed to be covered - like compression stocking and socks.  I paid a visit to the referral office on base and chatted with the rep and she found a hcpc code that allows full coverage.  When I replaced my first sets the bill was fully paid by my insurance.  The insurance office at the medical device company now knows what code to use for others with this same insurance, or others who have been denied since I believe that hcpc codes are universal.  Is it possible that this is a coding error? 

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  • vlnrph
    vlnrph Member Posts: 1,632
    edited March 2014

    SpecialK prompted me to remember a coding issue I also had. When I tried a new shop, they billed a sleeve as a stocking so of course was rejected. Even corrected, coverage was less than optimal because my copay plus the insurance company reimbursement was lower than what the item cost the store! 

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  • PersonalTrainer
    PersonalTrainer Member Posts: 21
    edited March 2014

    I don't think it's a coding issue.  What the insurance company has told me - both in an e-mail and over the phone - is that the policy my company has covers durable medical equipment, but it excludes compression.  When I pointed out that compression is the treatment for Lymphedema and under the Woman's Cancer Rights Act - it should be a covered benefit - they ignored that.  In fact, they've ignored me.  I asked for a Case Manager - nope, they don't call me back.  I thought my old insurance company was bad - this one is way worse.

    Anyway - where we are now, after my complaint to my State Insurance Commission is that Anthem asked an extension to answer the State.  They are having their "analyst"  look at my complaint to see if the law applies.  

    What nonsense - this has been a law since 1998 - this has never come up before?  Keep in mind - they are supposed to provide members with annual notice of the law.  So, they really shouldn't be surprised that this law exists. 

    I'm not happy with the State at this point either - they are allowing this foot dragging and the person assigned to my case had never heard of the Woman's Cancer Act at all. 

    I'm going to keep pushing though.  In the meantime - I ordered a couple of ready made sized sleeves to try.  My regular sleeves are becoming stretched out - I really do need new ones. 

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  • Binney4
    Binney4 Member Posts: 8,609
    edited March 2014

    PT, brava! Keep after 'em!  Strange as it may seem, in all the years I've hung out here (and on lots of other LE discussion boards) I have never heard of anyone taking on their insurance based on the WHCRAct. I've used it in my appeals, but only as an addendum to other avenues of complaint that my insurance company allowed. Go for it!

    And please do keep us updated. Hugs,
    Binney

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  • PersonalTrainer
    PersonalTrainer Member Posts: 21
    edited April 2014

    I'm posting an update on my insurance issue.  I WON!  The State agreed with me that the Woman's Health and Cancer Rights Act was very clear - treatment for Lymphedema must be covered.  As we all know, the treatment of choice is compression garments.  So, my company's insurance plan which does not cover compression garments is not legal.  The "certificate" must cover garments for BCRL.  

    This took some doing - the person at the State Insurance Commission who handled my complaint had initially never heard of this law, but once I told her about it, she looked it up and agreed it was pretty clear.  They did go back and forth for a bit - the insurance company tried to say that the law said they could go by the "certificate".  It does say this - but what it means is that deductibles and coinsurance apply - not that the company can write a plan that goes against the provisions of the law.

    Remember, this is a Federal law.  There are some exceptions - Medicare and Medicaid are exempt (which is why new legislation is important) and self-funded plans don't generally have to follow this law, some church plans may also be able to get out of it, but that's it. 

    If you've been denied coverage - don't be afraid to question it.  I got nowhere with the insurance company - they were totally ignoring me - so, I put in a complaint with my State's Insurance Commission.  It was easy to do - the form was right on the website and I just had to e-mail it to them.   

    I have to wear some sort of compression at all times - so, there was no way I was going to let this go without a fight.  Now they've given me a case manager and things are really looking better.  I'm calling to make an overdue appointment with the fitter at the supplier tomorrow.

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  • carol57
    carol57 Member Posts: 3,567
    edited April 2014

    Personaltrainer, WOWEEEEEE!  Let's pass a huge plate of brownies all around to celebrate together!  

    Good for you, kudos for not giving up, and thank you for the great lead on how to approach a state insurance commission.

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  • PersonalTrainer
    PersonalTrainer Member Posts: 21
    edited April 2014

    Thank you!  Yes, it is a relief.  It's just really rotten they tried to deny coverage in the first place, but as long as they get away with denials, they will do it.

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