Denied!

What, exactly, is the point of phoning the insurance company to find out if something is covered?  The insurer can say “yes” then change their minds and deny the claim when it is submitted.

When I phoned with two diagostic codes (728.71 – plantar fascitis, and 714.0 – RA), I was told that both of those conditions qualify a person for orthotics, so it would not be any problem having insurance pay for them.

The initial claim was denied.  The first appeal was ignored (not even recorded in the insurer’s computer).  Now I’ve received a letter stating that my second appeal was denied.  This was truly shocking, because it’s the first time I’ve ever had an appeal denied; they’ve always been approved before.  It took the insurer four months to find something in my policy that allows them to weasel out of what they told me at my initial inquiry:  apparently orthotics are only covered for people with diabetes or chronic peripheral vascular disease.

Thank God I’ve (so far) escaped my genetic heritage and don’t have diabetes.  I can’t even find a definitive explanation of the other condition; I do, unfortunately, have symptoms (and a risk factor), but nobody’s ever done the fairly simple test.  Quite frankly I don’t need or want another diagnosis and am done with this appeal.

Looks like I’ll be paying for my orthotics out-of-pocket.  That really really sucks.  I could use the $400.  Then again, they make such a huge difference in how my feet feel that they’re definitely worth having, so I’ll find a way to budget in replacements every year.

I’ve already contacted one of the people in charge of my company’s insurance coverage to suggest that this is one aspect of the plan that they might consider changing when the policy comes up for renewal.  The whole point of insurance is to cover stuff that’s needed for medical treatment.  Why they would deny orthotics for some conditions but cover them for others, I’ll never understand.  Then they added coverage for homeopathy.  How much sense does that make?!

Then there’s the doctor to consider.  His policy is very clear:  if insurance covers orthotics, he orders the orthotics and bills insurance; if not covered, cash in advance.  He should have had his money in October-November.  Now it’s the middle of March; the doctor doesn’t have his money and I don’t even have a bill yet.  The more I learn about how this system doesn’t work, the more I’m amazed that doctors ever accept insurance.

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8 thoughts on “Denied!

  1. You are so right.The system just doesn´t work.
    I think I will never understand why an insurance company why they approve one appeal and deny another.
    Sorry you have to pay for the orthotics out of your own pocket.This is just wrong.
    I hope you feel better soon.

  2. I’d reappeal it yet again and verify their reason otherwise if you haven’t already – can you get copies of the plan documents? PVD might be the same thing as PAD. What about folks with traumatic injury who need orthotics?

  3. I think this is a perfect example of why we need healthcare insurance reform. You have RA and Reynaud’s; both are clear diagnoses and your doctor clearly believes that orthodic shoes will relieve some of the pain you deal with day by day. Yet someone in an office somewhere has decided that if you don’t have peripheral vasculitis or diabetes, you don’t need shoes and they aren’t going to pay for them. I agree with Chelsea. Appeal again, but in the meantime, buy your shoes yourself. Perhaps you’ll end up with two pairs and save yourself $500 next year (the price will surely have gone up by then).

    Your doctor should be the one who decides what treatment you need for your condition, not your insurance company. Shame on them.

  4. What a bummer! Sometimes you wonder who is sitting at a desk somewhere making these decisions.

    The plantar fascitis is probably caused by the RA as its the tendon on the bottom of your foot connected to the heel bone (the other is the achilles and both are affected by RA).

    Have you ever tried SuperFeet inserts? They’re around $35. My physical therapist recommended them and said they are as good as the $400 custom orthotics. I use the green ones (most support).

  5. Sometimes, if the doctor writes a Strongly Worded Letter for you, you can get decisions reversed. Other times, you can’t. I’ve had it go both ways for me. First, they denied my PT claim, but finally approved it after the both the PT and my MD wrote supporting letters. (That was $4K!). Next, they denied US as experimental. Despite the involvement of three different MDs, they refused to budge. Ultimately, the hospital removed the $3K charge. Now, however, the MD wants me to go for an MRI and I can’t bring myself to do it. Yes, the BC says it’s covered. But, as you say and as we’ve all experienced, they can easily change their minds. Sigh.

  6. Have to say, I’m glad I live up here. True, things like the orthotics might not be covered by my company insurance plan, but the PT is, to a certain extent. And the MRI definitely would be, no questions asked, by the government. The system ain’t perfect, but it works and for that, especially now, I am eternally grateful. :) L

  7. Due to insured but not insured status and work that I cannot afford to take any time off from, I’ve had to make due with fashioning my own foot support. It’s taken months on end but I’ve got at least the plantar fascitis under better control. Cheap but bigger shoes, with two to three store bought arch supports, plus several of those little ball of feet gel cushions placed just so behind the toes and under the arch/heel have helped now with the plantar fascitis. Corn cushion on the side of my foot for the big callus over the bone at the base of my little toe. Now that I got those under control for about seventy bucks, I have a spot on the ball of my foot between two middle toes that is giving me problems. Will try moving the gel cushion around a bit more…..Also, used a foot splint my mom had, even though it was for the wrong foot, I wore it at night and during the day a few days and this helped the plantar stuff too.

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