Insurance Coverage

July 8, 2006

Jan

I have cigna PPO and they have denied me 3 appeals. Even though I got pre

authorization.

Good luck!

Cheri

-- Insurance coverage

Hi,

I had the surgery 3 yrs ago and am still fighting with my insurance

co. over coverage. Now they want to settle but are saying that

reasonable & customary charges would have been $6845 of which they

only want to pay a small amt. I need to find out from as many people

as possible who their insurance co was and what they paid. I would

really appreciate any help you all can give me. Thanks ahead of time.

Jan

December 27, 2006

You may need to use a code that coincides with the testing being

performed. If they do not match it will be declined. As an exmaple

having cholesterol levels drawn when the dx code is a rhinitis

(colds).

Toxic encephalogpathy may not require " metal testing " according to

BCBS. If your child were dx'd metal poisoning though, then those

tests would be needed. Not sure what tests your trying to have done,

but as a med billing person..this is usually the reason..the code

does not match the testing. They have certain tests that are used

for certain disorders or illnesses and that is all they pay for. IF

there is a discrepancy..they deny the claim or request reasoning

from the doctor for ususual expensive tests. This is normal for them

to do. Stinks for us though. BCBS is not fun..I have them for my dt

and have been billed $3.50 for blood work..they covered all but

three friggin dollars and fifty cents..and I had to pay that...and

this was for blood lead..which should be paid in full!

>

> Has anyone had trouble getting their DAN tests covered by Blue

Cross &

> Blue Shield PPO? We have used the codes: 275.8 Disorder of mineral

> metabolism and 349.82 Toxic encephalopathy. They are requesting a

> letter of medical necessity. Insurance has denied tests in the

past

> from Hicks and Pfeiffer. We are now seeing Dr. Usman and I know

several

> people with PPO insurance that have had their tests covered

without a

> problem.

>

> Thanks,

>

December 30, 2006

Thank you for your reply. When our insurance denies coverage, which I'm

pretty sure they are going to do based on the testing being

" experimental/investigational " ...what would be the best way to fight them? Can

we re-submit using

different codes?

Thanks again,

In a message dated 12/27/2006 3:45:33 PM Central Standard Time,

paxlforme@... writes:

You may need to use a code that coincides with the testing being

performed. If they do not match it will be declined. As an exmaple

having cholesterol levels drawn when the dx code is a rhinitis

(colds).

Toxic encephalogpathy may not require " metal testing " according to

BCBS. If your child were dx'd metal poisoning though, then those

tests would be needed. Not sure what tests your trying to have done,

but as a med billing person..this is usually the reason..the code

does not match the testing. They have certain tests that are used

for certain disorders or illnesses and that is all they pay for. IF

there is a discrepancy.there is a discrepancy.<WBR>.they deny the

from the doctor for ususual expensive tests. This is normal for them

to do. Stinks for us though. BCBS is not fun..I have them for my dt

and have been billed $3.50 for blood work..they covered all but

three friggin dollars and fifty cents..and I had to pay that...and

this was for blood lead..which should be paid in full!

December 30, 2006

Hi -

If you have trouble with the insurance company paying you can alwasy

contact the lab that performed the test and they might give you an

out of pocket rate.

We have had BCBS PPO deny paying for one of our tests. BCBS indicated

that it was experimental and would not pay for it. I was going to

appeal it, but after talking with the company that performed the test

they said that they never know which local BCBS company will deny the

tests and so they send it through for all. Since BCBS denied it they

went ahead and dropped the rate for me since I was paying out of

pocket. It went from over $500 to about $80. I was willing to pay $80

and decided not to appeal with BCBS. I hate dealing with insurance

companies.

Just another avenue....

-

>

> Has anyone had trouble getting their DAN tests covered by Blue

Cross &

> Blue Shield PPO? We have used the codes: 275.8 Disorder of mineral

> metabolism and 349.82 Toxic encephalopathy. They are requesting a

> letter of medical necessity. Insurance has denied tests in the past

> from Hicks and Pfeiffer. We are now seeing Dr. Usman and I know

several

> people with PPO insurance that have had their tests covered without

a

> problem.

>

> Thanks,

>

May 17, 2007

Hi Kamal Well this is wonderful news,, San is beautiful, you will like it.. now kaiser, that may be another story,, but I hope you will have a good outcome. I still do not understand why you are not on ribavirin or what is the thinking about not using it just because you are on dialysis,, do they feel it would be a waste of the drug because you are dialysed so often? My mom had Kaiser and while there were some things that I questioned, she seemed to like it ok.. and as far as co-pays, you should know that already, they should have told you what your co-pays would be for each doc you see.. it can vary depending upon which kind of policy you have. My mom had to pay 20.00 for every office call and 50.00 for each day she was hospitalized even when in a kaiser hosp... but what I CAN tell you is when my brother was dying, Kaiser took such good care of him and they were so attentive to our family needs... Let us know when you

arrive hon! jaxKamal Shah <kamalshah20@...> wrote: Hi all,I am going to be travelling from India to San , CA soon and will be staying there for a year or two. I am currently undergoing treatment for Hep C (Genotype 3) with a weekly shot of Pegasys 135 and NO ribavirin (because I am on dialysis). I will have Kaiser's coverage - the $30 copayment HMO plan. I am really unfamiliar with the way insurance works in the US. What I do know is that I will have no waiting period and will be

covered from when I reach the US. What I would like to know is under this plan, will there be a part of the cost of treatment that I will have to bear? If so, how much? Is there some website where I can find this information?-- ThanksKamal'Never ask a man what computer he uses.If it's a Mac, he'll tell you. If it's not, why embarrass him?' - Tom Clancy Jackie

May 17, 2007

I don't take ribavirin because it can cause serious anemia (more than the non dialysis HCV patiennts). Even Dr. Cecil agrees with this.Will Kaiser pay for the HCV treatment?ThanksKamal

On 5/17/07, Jackie on <redjaxjm@...> wrote:

Hi Kamal Well this is wonderful news,, San is beautiful, you will like it.. now kaiser, that may be another story,, but I hope you will have a good outcome. I still do not understand why you are not on ribavirin or what is the thinking about not using it just because you are on dialysis,, do they feel it would be a waste of the drug because you are dialysed so often?

My mom had Kaiser and while there were some things that I questioned, she seemed to like it ok.. and as far as co-pays, you should know that already, they should have told you what your co-pays would be for each doc you see.. it can vary depending upon which kind of policy you have. My mom had to pay 20.00 for every office call and 50.00 for each day she was hospitalized even when in a kaiser hosp... but what I CAN tell you is when my brother was dying, Kaiser took such good care of him and they were so attentive to our family needs... Let us know when you

arrive hon! jaxKamal Shah <kamalshah20gmail

> wrote: Hi all,I am going to be travelling from India to San , CA soon and will be staying there for a year or two. I am currently undergoing treatment for Hep C (Genotype 3) with a weekly shot of Pegasys 135 and NO ribavirin (because I am on dialysis). I will have Kaiser's coverage - the $30 copayment HMO plan. I am really unfamiliar with the way insurance works in the US. What I do know is that I will have no waiting period and will be

covered from when I reach the US. What I would like to know is under this plan, will there be a part of the cost of treatment that I will have to bear? If so, how much? Is there some website where I can find this information?

-- ThanksKamal'Never ask a man what computer he uses.If it's a Mac, he'll tell you. If it's not, why embarrass him?' - Tom Clancy

Jackie

-- ThanksKamal'Never ask a man what computer he uses.If it's a Mac, he'll tell you. If it's not, why embarrass him?' - Tom Clancy

May 17, 2007

Oh ok,, well the chances of you clearing with Interferon alone is greatly reduced without the riba,, but they must know what hey are doing hon,, Im sure that Kaiser will pay for your treatment,, they should,, Kamal Shah <kamalshah20@...> wrote: I don't take ribavirin because it can cause serious anemia (more than the non dialysis HCV patiennts). Even Dr. Cecil agrees with this.Will Kaiser pay for the HCV treatment?ThanksKamal On 5/17/07, Jackie on <redjaxjm > wrote: Hi Kamal Well this is wonderful news,, San is beautiful, you will like it.. now kaiser, that may be another story,, but I hope you will have a good outcome. I still do not understand why you are not on ribavirin or what is the thinking about not using it just because you are on dialysis,, do they feel it would be a waste of the drug because you are dialysed so often? My mom had Kaiser and while there were some things that I questioned, she seemed to like it ok.. and as far as co-pays, you should know that already, they should have told you what your co-pays would be for each doc you see.. it can vary depending upon which kind of policy you

have. My mom had to pay 20.00 for every office call and 50.00 for each day she was hospitalized even when in a kaiser hosp... but what I CAN tell you is when my brother was dying, Kaiser took such good care of him and they were so attentive to our family needs... Let us know when you arrive hon! jax Kamal Shah <kamalshah20gmail > wrote: Hi all,I am going to be travelling from India to San , CA soon and will be staying there for a year or two. I am currently undergoing treatment for Hep C (Genotype 3) with a weekly shot of Pegasys 135 and NO ribavirin (because I am on dialysis). I will have Kaiser's coverage - the $30 copayment HMO plan. I am really unfamiliar with the

way insurance works in the US. What I do know is that I will have no waiting period and will be covered from when I reach the US. What I would like to know is under this plan, will there be a part of the cost of treatment that I will have to bear? If so, how much? Is there some website where I can find this information? -- ThanksKamal'Never ask a man what computer he uses.If it's a Mac, he'll tell you. If it's not, why embarrass him?' - Tom Clancy Jackie -- ThanksKamal'Never ask a man what computer he uses.If it's a Mac, he'll tell you. If it's not, why embarrass him?' - Tom Clancy Jackie

May 18, 2007

As far as I know Kaiser pays for the treatment of hepatitis c ..

Re: Insurance Coverage

I don't take ribavirin because it can cause serious anemia (more than the non dialysis HCV patiennts). Even Dr. Cecil agrees with this.Will Kaiser pay for the HCV treatment?ThanksKamal

On 5/17/07, Jackie on <redjaxjm > wrote:

Hi Kamal

Well this is wonderful news,, San is beautiful, you will like it.. now kaiser, that may be another story,, but I hope you will have a good outcome. I still do not understand why you are not on ribavirin or what is the thinking about not using it just because you are on dialysis,, do they feel it would be a waste of the drug because you are dialysed so often?

My mom had Kaiser and while there were some things that I questioned, she seemed to like it ok.. and as far as co-pays, you should know that already, they should have told you what your co-pays would be for each doc you see.. it can vary depending upon which kind of policy you have. My mom had to pay 20.00 for every office call and 50.00 for each day she was hospitalized even when in a kaiser hosp... but what I CAN tell you is when my brother was dying, Kaiser took such good care of him and they were so attentive to our family needs...

Let us know when you arrive hon!

jax

Kamal Shah <kamalshah20gmail > wrote:

Hi all,I am going to be travelling from India to San , CA soon and will be staying there for a year or two. I am currently undergoing treatment for Hep C (Genotype 3) with a weekly shot of Pegasys 135 and NO ribavirin (because I am on dialysis). I will have Kaiser's coverage - the $30 copayment HMO plan. I am really unfamiliar with the way insurance works in the US. What I do know is that I will have no waiting period and will be covered from when I reach the US. What I would like to know is under this plan, will there be a part of the cost of treatment that I will have to bear? If so, how much? Is there some website where I can find this information? -- ThanksKamal'Never ask a man what computer he uses.If it's a Mac, he'll tell you. If it's not, why embarrass him?' - Tom Clancy Jackie

-- ThanksKamal'Never ask a man what computer he uses.If it's a Mac, he'll tell you. If it's not, why embarrass him?' - Tom Clancy

May 18, 2007

Usually if there is any cost associated it is due when the meds come . You may have a copay but I am not what it would be .

Insurance Coverage

Hi all,I am going to be travelling from India to San , CA soon and will be staying there for a year or two. I am currently undergoing treatment for Hep C (Genotype 3) with a weekly shot of Pegasys 135 and NO ribavirin (because I am on dialysis). I will have Kaiser's coverage - the $30 copayment HMO plan. I am really unfamiliar with the way insurance works in the US. What I do know is that I will have no waiting period and will be covered from when I reach the US. What I would like to know is under this plan, will there be a part of the cost of treatment that I will have to bear? If so, how much? Is there some website where I can find this information?-- ThanksKamal'Never ask a man what computer he uses.If it's a Mac, he'll tell you. If it's not, why embarrass him?' - Tom Clancy

May 19, 2007

Hi Susie,

coverage varies so widely. we were lucky to get 100% coverage. we have

Kaiser in Northern California. A lot of companies deny coverage, but

on appeal many will cover. Some policies actually have an explicit

exclusion for cranial remolding devices, and then it is difficult to

appeal. You really just have to check out your own insurance.

Also the cost varies widely. I think DOCbands are usually close to

$3000 or more. Hanger and STARbands vary more. Probably $1800 -

$3000+. The cost of living here is very high. if we had to pay for

our band I think it would have been about $3000.

take care.-christine

sydney 16 mo starband grad

>

> Hello! I know all insurances are different but do most companies tend

> to cover treatment for plagiocephaly (i.e. helmets)? Any feedback would

> be greatly appreciated. If not, how much do bands/helmets cost? I've

> heard thousands of dollars. Thanks!

>

> Susie

>

May 19, 2007

I agree with , coverage varies so much, even within insurance

companies. We also have Kaiser in Northern California and our band was

covered at 80%. Our particular plan through my husband's company covered

Durable Medical Equipment (DME) at 80% and the band was considered to be

DME. The best thing to do is see if your insurance plan has any DME

coverage.

Our STARband was $2,800 and that included the cost of the band and all of

the fitting appointments. I've heard that some band providers give you a

discount if you pay the amount up front or in cash.

Molly

California

Nicolas, 19 months, tort & plagio, STARband 4/25/06-9/12/06, Graduate!

, 4

, 7.5

Re: Insurance Coverage

Hi Susie,

coverage varies so widely. we were lucky to get 100% coverage. we have

Kaiser in Northern California. A lot of companies deny coverage, but on

appeal many will cover. Some policies actually have an explicit exclusion

for cranial remolding devices, and then it is difficult to appeal. You

really just have to check out your own insurance.

Also the cost varies widely. I think DOCbands are usually close to $3000 or

more. Hanger and STARbands vary more. Probably $1800 - $3000+. The cost of

living here is very high. if we had to pay for our band I think it would

have been about $3000.

take care.-christine

sydney 16 mo starband grad

>

> Hello! I know all insurances are different but do most companies tend

> to cover treatment for plagiocephaly (i.e. helmets)? Any feedback would

> be greatly appreciated. If not, how much do bands/helmets cost? I've

> heard thousands of dollars. Thanks!

>

> Susie

>

For more plagio info

May 19, 2007

from what I have seen on here it varies and even if they do cover you may have to appeal. OUr incusrance is saying the docband is out of network so will only be covered at 60% after we meet our $750 out of network deductible or we could get a hanger in network covered at 80% after $250 deductible. The docband costs $3000 but you get a 10% discount if you pay up front (what we are doing). Hanger is cheaper and probably will be even more than that b/c outr insurance probably has a negoitiated rate. We opted to go with CT/docband though b/c more experience and better support so if there was ever any question they would have another expert to ask, our Hanger facility only has one person that bands so wouldnt have anyone to consult.

On 5/19/07, susiesunshine75 <susiesunshine75@...> wrote:

Hello! I know all insurances are different but do most companies tend to cover treatment for plagiocephaly (i.e. helmets)? Any feedback would be greatly appreciated. If not, how much do bands/helmets cost? I've heard thousands of dollars. Thanks!Susie -- -SAHmommy and leader to;

-5th grade G & T, Jr GS, soccer, cello-1st grade, Brownie; school mtg 5/22-cosleeping, loving to learn always with 2 yr old flairph-cosleeping, babywearing, breastfeeding, all over the place already; NS 5/30, CT casting 6/1

" As the family goes, so goes the nation and so goes the whole world in which we live. " PJPII

May 19, 2007

Hi Susie,

In addition to every company being different...every policy within

UHC (or the others) is different. IT all depends on the benefits

that your employeer (or whomever you get the insurance from) can

get. For instance, I taught and had UHC. Now, I am a SAHM and

have UHC through my husbands work. The UHC through my husband's

work provides more benefits. You'll have to check your specific

policy for what is covered and what isn't. We were reimbursed 80%

with the UHC Choice Plus Plan. I can send you a copy of my appeal

if you'd like.

> >

> > Hello! I know all insurances are different but do most

companies tend

> > to cover treatment for plagiocephaly (i.e. helmets)? Any

feedback would

> > be greatly appreciated. If not, how much do bands/helmets cost?

I've

> > heard thousands of dollars. Thanks!

> >

> > Susie

> >

>

> --

> -SAHmommy and leader to;

> -5th grade G & T, Jr GS, soccer, cello

> -1st grade, Brownie; school mtg 5/22

> -cosleeping, loving to learn always with 2 yr old flair

> ph-cosleeping, babywearing, breastfeeding, all over the place

already;

> NS 5/30, CT casting 6/1

>

> " As the family goes, so goes the nation and so goes the whole

world in which

> we live. " PJPII

>

June 2, 2007

Rogene ~

Why thank you my dear ! ! I liked it ! ! and it worked for me ! !

The best thing about how I handelled my insurance application is:

I felt like I did it in all honesty,

well, ...........what they considered honest,

I honestly used what they were telling me, and the public ~

Have a beautiful day !

Love DedeSee what's free at AOL.com.

June 2, 2007

Dede . . . Brilliant reasoning! . . . Thanks! Rogene

July 11, 2007

We had our band covered by Kaiser in Northern California. It was considered

to be Durable Medical Equipment (DME). In our case, our DME coverage was

80% so all we had to pay was 20% of the cost of the band. I know other

people in Nor Cal Kaiser and their Kaiser plan covered 100% of DME. So,

check and see what your DME coverage is as it varies from plan to plan and

see if you can get the band covered as DME. Feel free to contact me offline

if you want specific details regarding our doctor and our band provider -

mafoley@....

Molly

California

Nicolas, 21 months, tort & plagio, STARband 4/25/06-9/12/06, Graduate!

, 4

, 7.5

insurance coverage

I live in , CO and am doing a second level appeal for my

daughters starband (or custom cranial orthosis, as they call it). We

have Kaiser insurance and basically they are telling us that Kaiser

never covers this because Medicare does not cover it. Of course they

also say it is not medically necessary but I feel I have enough info

to fight that claim. What I'm looking for is anyone and everyone who

has Kaiser (especially anyone in the Denver/Boulder area) and has had

their childs band (any band for plagiocephaly) covered (usually at

80%). It would be very helpful to my appeal process to be able to give

specific names of patients who had the same service covered. If you

can help me, please let me know.

Thanks in advance for your help,

For more plagio info

July 12, 2007

we have Kaiser in northern CA and were covered 100%. Our specialist

told us even withing Kaiser Norther CA coverage varies depending on

the plan that your employer chooses.

-christine

sydney 18 mo starband grad

>

> I live in , CO and am doing a second level appeal for my

> daughters starband (or custom cranial orthosis, as they call it). We

> have Kaiser insurance and basically they are telling us that Kaiser

> never covers this because Medicare does not cover it. Of course they

> also say it is not medically necessary but I feel I have enough info

> to fight that claim. What I'm looking for is anyone and everyone who

> has Kaiser (especially anyone in the Denver/Boulder area) and has had

> their childs band (any band for plagiocephaly) covered (usually at

> 80%). It would be very helpful to my appeal process to be able to give

> specific names of patients who had the same service covered. If you

> can help me, please let me know.

>

> Thanks in advance for your help,

>

July 12, 2007

I don't live in CO but I'm also fighting UHC right now

and just wanted to say good luck and I hope you get

it.

I think it's a shame that we have to fight like this

to get the care our babies deserve.

--- gkuttrus <gkuttrus@...> wrote:

> I live in , CO and am doing a second level

> appeal for my

> daughters starband (or custom cranial orthosis, as

> they call it). We

> have Kaiser insurance and basically they are telling

> us that Kaiser

> never covers this because Medicare does not cover

> it. Of course they

> also say it is not medically necessary but I feel I

> have enough info

> to fight that claim. What I'm looking for is anyone

> and everyone who

> has Kaiser (especially anyone in the Denver/Boulder

> area) and has had

> their childs band (any band for plagiocephaly)

> covered (usually at

> 80%). It would be very helpful to my appeal process

> to be able to give

> specific names of patients who had the same service

> covered. If you

> can help me, please let me know.

>

> Thanks in advance for your help,

>

________________________________________________________________________________\

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July 13, 2007

We have Kaiser - Southern California. Ours was covered 80% b/c there was DME or Durable Medical Equipment coverage and the Kaiser dr gave us the prescription. DId you see a Craniofacial dr? Our Cranio dr looked it up and saw that we had coverage before she wrote the script.

HTH!!!

Jen and Luli - 19 mo.

Left Tort - Right Plagio - Hanger Band Grad - CA

tallulah jayne

www.babiesonline.com/babies/j/jens5th/