Vest and Insurance Denial

[Gentrygirl]

When Logan was first diagnosed, our insurance (BCBS) was denying all coverage of any treatment for him based on a pre-existing condition clause. That passed after 12 months and they started covering (of course federal law would protect now anyhow). He had been donated a vest, which worked great until recently. Doctors prescribed one for him, and now insurance is denying it, saying there is no documentation that there is no competent caregiver. Has anyone worked through this, with or without success in an appeal?  

 

[Gentrygirl]

When Logan was first diagnosed, our insurance (BCBS) was denying all coverage of any treatment for him based on a pre-existing condition clause. That passed after 12 months and they started covering (of course federal law would protect now anyhow). He had been donated a vest, which worked great until recently. Doctors prescribed one for him, and now insurance is denying it, sayingthere is no documentation that there is no competent caregiver. Has anyone worked through this, with or without success in an appeal?

 

[Gentrygirl]

When Logan was first diagnosed, our insurance (BCBS) was denying all coverage of any treatment for him based on a pre-existing condition clause. That passed after 12 months and they started covering (of course federal law would protect now anyhow). He had been donated a vest, which worked great until recently. Doctors prescribed one for him, and now insurance is denying it, sayingthere is no documentation that there is no competent caregiver. Has anyone worked through this, with or without success in an appeal?<BR>

 

[Ratatosk]

We were told by the vest company that usually insurance will deny the vest initially and there's an appeal process which they handle. The appeal consisted of questions regarding hospitalizations, treatment for pseudo, medications DS was taking. The vest was approved; however, that first year they checked to see if we were being compliant in terms of calling to ask hours on the vest. We ended up having to pay $500 out of pocket, which was great considering we'd originally been told we were responsible for 20%. So IMO -- appeal, appeal, appeal...

 

[Ratatosk]

We were told by the vest company that usually insurance will deny the vest initially and there's an appeal process which they handle. The appeal consisted of questions regarding hospitalizations, treatment for pseudo, medications DS was taking. The vest was approved; however, that first year they checked to see if we were being compliant in terms of calling to ask hours on the vest. We ended up having to pay $500 out of pocket, which was great considering we'd originally been told we were responsible for 20%. So IMO -- appeal, appeal, appeal...

 

[Ratatosk]

We were told by the vest company that usually insurance will deny the vest initially and there's an appeal process which they handle. The appeal consisted of questions regarding hospitalizations, treatment for pseudo, medications DS was taking. The vest was approved; however, that first year they checked to see if we were being compliant in terms of calling to ask hours on the vest. We ended up having to pay $500 out of pocket, which was great considering we'd originally been told we were responsible for 20%. So IMO -- appeal, appeal, appeal...

 

[Rebjane]

Our insurance co. paid for my daughter's vest 100%. She got her's when she has 2 1/2 years old. When we first got the VEST a couple times a year for the beginning; someone would call to find out how many hours were logged onto the vest but after that nada.

I would do a couple thing; contact your CF social worker to to some legwork on this. I would also think about contacting a lawyer (if you have a friend who is a lawyer) or through the Cystic Fibrosis Foundation.

This REALLY irks me; The VEST was invented for CF patients....It is a life-saving device. Also, since your insurance co. is looking at the bottom line; maybe letting them know that this VEST will keep him out of the hospital which will SAVE them $. The VEST costs what $15,000 but a a couple days in the hospital for a CF'er will cost that much and more!

 

[Rebjane]

Our insurance co. paid for my daughter's vest 100%. She got her's when she has 2 1/2 years old. When we first got the VEST a couple times a year for the beginning; someone would call to find out how many hours were logged onto the vest but after that nada.

I would do a couple thing; contact your CF social worker to to some legwork on this. I would also think about contacting a lawyer (if you have a friend who is a lawyer) or through the Cystic Fibrosis Foundation.

This REALLY irks me; The VEST was invented for CF patients....It is a life-saving device. Also, since your insurance co. is looking at the bottom line; maybe letting them know that this VEST will keep him out of the hospital which will SAVE them $. The VEST costs what $15,000 but a a couple days in the hospital for a CF'er will cost that much and more!

 

[Rebjane]

Our insurance co. paid for my daughter's vest 100%. She got her's when she has 2 1/2 years old. When we first got the VEST a couple times a year for the beginning; someone would call to find out how many hours were logged onto the vest but after that nada.
<br />
<br />I would do a couple thing; contact your CF social worker to to some legwork on this. I would also think about contacting a lawyer (if you have a friend who is a lawyer) or through the Cystic Fibrosis Foundation.
<br />
<br />This REALLY irks me; The VEST was invented for CF patients....It is a life-saving device. Also, since your insurance co. is looking at the bottom line; maybe letting them know that this VEST will keep him out of the hospital which will SAVE them $. The VEST costs what $15,000 but a a couple days in the hospital for a CF'er will cost that much and more!

 

[edan]

Hi. This topic was posted last fall. Here was my response then:
"We were denied with Blue Cross as well. My clinic's social worker recommended I ask for a case manager. It worked! My case manager knew about CF well (ex nurse who already dealt with CF patients). She coordinated for me what I needed (I.E. more info from the clinic, etc). What happened was the local managed care branch at Blue Cross denied the vest in writing to me due to "no other forms of airway clearance demonstrated as not working". But when I got the case manager involved she contacted them and they said they just needed more documentation from the clinic. It is their job just to deny, deny, deny.

We had NEVER had a hospitalization or cultured anything more than HIB at the time. After 6-8 weeks of fighting, the vest was finally delivered on a saturday. We were hospitalized the following monday due to an exacerbation.

The vest company also said they would call, but haven't. The insurance company said it was "on loan" for 3 months to make sure it was working. Not sure yet how we will get through that one in a month or so.

Ask for a case manager at Blue Cross. It really helped us so far. "

The link is at <A HREF="http://forums.cysticfibrosis.com/messageview.cfm?catid=6&threadid=59557">http://forums.cysticfibrosis.com/messageview.cfm?catid=6&threadid=59557</A>

Hope this helps,
Edan

 

[edan]

Hi. This topic was posted last fall. Here was my response then:
"We were denied with Blue Cross as well. My clinic's social worker recommended I ask for a case manager. It worked! My case manager knew about CF well (ex nurse who already dealt with CF patients). She coordinated for me what I needed (I.E. more info from the clinic, etc). What happened was the local managed care branch at Blue Cross denied the vest in writing to me due to "no other forms of airway clearance demonstrated as not working". But when I got the case manager involved she contacted them and they said they just needed more documentation from the clinic. It is their job just to deny, deny, deny.

We had NEVER had a hospitalization or cultured anything more than HIB at the time. After 6-8 weeks of fighting, the vest was finally delivered on a saturday. We were hospitalized the following monday due to an exacerbation.

The vest company also said they would call, but haven't. The insurance company said it was "on loan" for 3 months to make sure it was working. Not sure yet how we will get through that one in a month or so.

Ask for a case manager at Blue Cross. It really helped us so far. "

The link is at <A HREF="http://forums.cysticfibrosis.com/messageview.cfm?catid=6&threadid=59557">http://forums.cysticfibrosis.com/messageview.cfm?catid=6&threadid=59557</A>

Hope this helps,
Edan

 

[edan]

Hi. This topic was posted last fall. Here was my response then:
<br />"We were denied with Blue Cross as well. My clinic's social worker recommended I ask for a case manager. It worked! My case manager knew about CF well (ex nurse who already dealt with CF patients). She coordinated for me what I needed (I.E. more info from the clinic, etc). What happened was the local managed care branch at Blue Cross denied the vest in writing to me due to "no other forms of airway clearance demonstrated as not working". But when I got the case manager involved she contacted them and they said they just needed more documentation from the clinic. It is their job just to deny, deny, deny.
<br />
<br />We had NEVER had a hospitalization or cultured anything more than HIB at the time. After 6-8 weeks of fighting, the vest was finally delivered on a saturday. We were hospitalized the following monday due to an exacerbation.
<br />
<br />The vest company also said they would call, but haven't. The insurance company said it was "on loan" for 3 months to make sure it was working. Not sure yet how we will get through that one in a month or so.
<br />
<br />Ask for a case manager at Blue Cross. It really helped us so far. "
<br />
<br />The link is at <A HREF="http://forums.cysticfibrosis.com/messageview.cfm?catid=6&threadid=59557">http://forums.cysticfibrosis.com/messageview.cfm?catid=6&threadid=59557</A>
<br />
<br />Hope this helps,
<br />Edan
<br />

 

[edan]

And as an update, the vest company did call to check hours used and the insurance company did pay for it in full a few months later.

 

[edan]

And as an update, the vest company did call to check hours used and the insurance company did pay for it in full a few months later.

 

[edan]

And as an update, the vest company did call to check hours used and the insurance company did pay for it in full a few months later.
<br />

 

[dledwith]

sometimes insurance can be a pain in the butt. i heard that some people buy their vests on ebay for cheap <img src="i/expressions/face-icon-small-wink.gif" border="0"> <img src="i/expressions/face-icon-small-wink.gif" border="0">

just a thought

 

[dledwith]

sometimes insurance can be a pain in the butt. i heard that some people buy their vests on ebay for cheap <img src="i/expressions/face-icon-small-wink.gif" border="0"> <img src="i/expressions/face-icon-small-wink.gif" border="0">

just a thought

 

[dledwith]

sometimes insurance can be a pain in the butt. i heard that some people buy their vests on ebay for cheap <img src="i/expressions/face-icon-small-wink.gif" border="0"> <img src="i/expressions/face-icon-small-wink.gif" border="0">
<br />
<br />just a thought

 

[Gentrygirl]

Thanks, all. Edan, I figured there were others that had been through this, but really couldn't find the topic in a search. Like everyone else, juggling the demands of life and work on top of CF, I always know you all have tips that will work and save me time! Insurance companies seem so big and so hard to fight. So the smartest thing is to start by asking for a case worker from the Insurance company? I'll do that first. Intuitively, it doesn't seem like the people that are working against us are going to be the ones that will provide us help, but I'll definitely follow your advice! Thanks for the help!!

 

[Gentrygirl]

Thanks, all. Edan, I figured there were others that had been through this, but really couldn't find the topic in a search. Like everyone else, juggling the demands of life and work on top of CF, I always know you all have tips that will work and save me time! Insurance companies seem so big and so hard to fight. So the smartest thing is to start by asking for a case worker from the Insurance company? I'll do that first. Intuitively, it doesn't seem like the people that are working against us are going to be the ones that will provide us help, but I'll definitely follow your advice! Thanks for the help!!