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.