Wednesday, April 29, 2009

What exactly is the definition of "Experimental"?

BLOG? I have a blog? Oh yeah.

Sorry, seems like we've been dealing with too much stuff to post about. Some good - birthdays; some not so good - family situations, job situations, family's job situations...

One thing I did want to write about was yet another thing we've been dealing with - our health insurance company.

A couple of months ago, we had to replace Kelly's mouthpiece. It is an oral device that helps with his sleep apnea. The last one we bought was nearly four years ago and was starting to crack. The only place, at least in San Antonio, to get one is through a dentist who does nothing but make oral appliances for sleep apnea. Because this dentist in not in our medical network, we paid for the device out-of-pocket (which was quite a chuck o' money, lemme tell ya!), and filed the claim.

Four years ago when we bought the last one, we had the same insurance company. At first they denied that claim because it "wasn't a medical, but a dental issue." We submitted paperwork, like a letter of medical necessity from Kelly's medical doctor saying that is was a treatment for a medical condition and the results from his sleep lab. So they approved it and paid for it.

I was hoping that since we've already been through this once, it wouldn't be as hard this time. We thought we'd be smart. This time when we submitted the claim, we went ahead and submitted 13 pages worth of paperwork, including: 2 letters of medical necessity from two doctors, a prescription for the mouthpiece from a doctor, his sleep lab results, etc.

Two weeks later, we received a letter denying the claim, but stating that they had insufficient records to make a determination. But that if we would submit documents they would reconsider.


Needless to say Kelly called and found out that they "never received the documents." Since they were in the same envelope as the claim we found that too hard to believe. So we re-sent the documents and was told to wait 4-6 weeks. When 6 weeks had gone by without a word, we called and found out a determination had been made 2 weeks before, but a letter was never sent to us. Our claim was denied because it was considered by the doctor on staff who reviewed the claim to be "an experimental treatment, and so not covered."

AHHHHH! We spent the next two days gathering additional paperwork. This time we sent copies of the paperwork showing they had paid for the same type of device four years earlier, and it wasn't considered experimental then! I also found a report put out by the American Academy of Sleep Doctors, spelling out the parameters for using oral appliances. In it, they clearly specify that oral devices can be used for cases such as Kelly's and are no longer experimental. We sent off the packet and waited, wondering.

Yesterday we received a letter saying that the claim had been approved and that payment would follow within 30 days. Hallelujah! I just love insurance companies, don't you?


Candace said...

Way to persevere guys!!!!

Jeanie said...

Glad you kept on them. I don't "Love" mine, but I too will fight for what I know my hubby works hard to get. I wish we had vision. Oh well : )

Tami said...

Believe me, Jeanie, when I was talking about loving the insurance company, it was completely tongue in cheek. ;-)