Lymphedema and Insurance Companies

Websites with info on coverages with various insurance companies

How to Appeal an Insurance Denial

Letter of Medical Necessity

Patient Advocacy Sites

Please note - these are general guidelines - you will have to contact your individual plans for more specifics. You can also find information on appealing insurance company denials, how to get approval for lymphedema treatments.

May 22, 2008

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For State by State information on filing an complaint with the insurance commissioner - type in How to file an Insurance Complaint - in your browser then scroll until you find your state

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Filing a Complaint With Your State Insurance Commissioner

From Bobbie Sage

State insurance commissioners resolve thousands of complaints every year. Complaints vary from disputes with insurance companies about how one's claim was handled to problems with the sale and service of an insurance policy. If you feel your insurance company has not been fair with your claim or policy, you have the right to file a complaint with your state insurance commissioner.

If you decide you need to file a complaint, there are a few things you will want to do or be prepared to do. First, go to your state insurance commissioner's web site and find out what the processs is to file a complaint. Many state insurance commissioners will have a complaint form available to download or fill out online. Once you know how to start the process, you will want to compile every piece of documentation that pertains to the complaint and start keeping records of all phone conversatins and agent contacts. Most all insurance companies have large claims departments and service call centers where you will almost always speak to a new person each time you contact the company, so it is important for you to keep your own records of all conversaions with the insurance company. Once you have your documents together and know how to file the complaint, it is now time to officially file it.

Now that the complaint is filed, your state insurance commissioner's office will likely contact you asking for any additional documentation they will need. In most cases the next step the commissioner will take is to send a copy of the complaint to the insurance company and give them a designated response time. Most likely, if the commissioner feels the response is adequate, they will send you a copy of the explanatory letter. But, if the commissioner feels the response from the company is not adequate, your case will probably be taken over by a state designated person that will work with you and the company to resolve the issue and to find out if any laws were broken.

One important thing to remember in the complaint process is that even if your case is assigned a state designated person to try to resolve the situation, that person cannot act as your attorney. Depending on what is at stake due to the complaint and your confidence in dealing with the insurance company, hiring an attorney to represent you should always be a consideration.

Important disclaimer information about this About site.

http://personalinsure.about.com/cs/whattoexpect/a/aa031604a.htm

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NLN - Draft of Insurance Appeal Letter

http://www.lymphnet.org/insuranceletter.html

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Lymphedema Questionnaire - Search Data Base

http://www.sleepless.com/lymphedema/view.php

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LymphaCare Lymphedema Pumps and ReidSleeves - Insurance and Managed Care

http://www.lymphedemapumps.com/generic4.html

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Aetna - Compression Garmets

http://www.aetna.com/cpb/medical/data/400_499/0482.html

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Aetna - Lymphedema Treatments

http://www.aetna.com/cpb/medical/data/1_99/0069.html

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Blue Cross - Lymphedema Guidelines

example - example - please contact your own individual state plan

http://notesnet.carefirst.com/ecommerce/medicalpolicy.nsf/vwwebtablex/d823995578a07ce98525709e0044c3b6?OpenDocument

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Blue Cross - Lymphadema Devices, Intermittent Pneumatic Devices, Compression Garmets

example - please contact your own individual state plan

http://www.bcbsnc.com/services/medical-policy/pdf/lymphedema_pumps_sequential_pneumatic_compression_device.pdf

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Blue Cross Medical Coverage Guidelines

http://www.bcbsfl.com/MCG/index.cfm?fuseaction=MCGHome.MainFrame&filename=guidelines/homepage.cfm

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Medical Necessity Statement

Lymphedema garments and bandages

http://www.jovipak.com/pdf/medical.pdf

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National Patient Advocate Foundation

http://www.npaf.org/

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Insurance Reimbursement Information

Circaid

http://www.lymphedema.biz/Insurance/InsReimPkg.pdf

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The Alliance of Claims Assistance Professionals

Offers assistance in getting insurers to pay for experimental treatments, as well as other reimbursement and billing problems

Toll-free 877-275-8765

http://www.claims.org

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National Insurance Consumer Helpline

Resource Description

The National Insurance Consumer Helpline is a telephone hotline that offers consumer support for queries and problems relating to insurance needs. Printed materials are also available.

Monday through Friday 800-942-4242. 1001 Pennsylvania Avenue NW Washington, DC 20004 800-942-4242

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Patient Advocacy Coalition

303-744-7667

The Coalition focuses on assisting people in the appeals process when an insurance company has denied coverage for medical treatments. They provide free advice and support on how to present a comprehensive and compelling case

http://www.patientadvocacy.net

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Patient Advocate Foundation (PAF)

800-532-5274

help@patientadvocate.org

This organization serves as an active liaison between the patient and their insurer, employer and/or creditors to resolve insurance, job discrimination and/or debt crisis matters relative to their diagnosis

http://www.patientadvocate.org

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Health Insurance Association of America (HIAA)

202-824-1600

A trade association that serves as the voice of health insurance. Publishes guides to various kinds of insurance (call or see the Web site):
"The Consumer’s Guide to Disability Insurance"
"The Consumer’s Guide to Health Insurance"
"The Consumer’s Guide to Long-Term Care Insurance"
"The Consumer’s Guide to Medicare Supplement Insurance"

http://www.hiaa.org

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A Consumer Guide to Getting and Keeping Health Insurance

Has information on individual and group plans specifically for each state

http://www.healthinsuranceinfo.net/

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COBRA (Consolidated Omnibus Budget Reconciliation Act)

Department of Labor

202-219-8776

COBRA requires that most employers sponsoring group health plans offer employees and their families the opportunity for a temporary extension of health coverage (called continuation coverage; usually at least 18 months) in certain instances where coverage under the employee’s plan would otherwise end. You must apply within 60 days of you or your spouse ending their job. You must pay the monthly premium for it, but by law it is your right to be covered by the health insurance policy you started with.

http://www.dol.gov/ebsa/newsroom/fscobra.html

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Policy Information Pipeline

Private Insurance

WHAT SHOULD BE IN A LETTER OF MEDICAL NECESSITY?

A skillfully drafted letter of medical necessity is an essential part of a request for funding for assistive technology. A letter of medical necessity, whether being submitted to the Department of Human Services, a private insurance company or other funding source, should contain the information needed to convince the reader that the requested assistive technology is necessary to meet the medical needs of the person for whom the assistive technology is being requested. This fact sheet is intended as a guide to preparing such a letter of medical necessity.

The letter of medical necessity should be written by a medical professional familiar with the requesting party's medical condition. The professional should briefly describe their credentials and relationship to the requesting party. This professional may be a physician, a nurse, a physical therapist, an occupational therapist or other medical professional. However, note that most funding sources require a physician's prescription as part of the funding request. Therefore, letters of medical necessity not written by a physician should be endorsed by a physician or accompanied by a physician's prescription.

ELEMENTS OF A LETTER OF MEDICAL NECESSITY

1. Disability Description - The letter should contain, usually at the beginning, a thorough description of the requesting party's disability. This description should include an explanation of how the disability affects the requesting party's function. For example, the affects of the disability on the use and function of the requesting party's legs. The disabling condition(s) and/or functional limitation(s) which necessitate the request for the assistive technology should be highlighted.

2. Assistive Technology Description - The assistive technology being requested should be described in some detail. A more thorough description is required when the requested technology is new, unique, customized or not frequently requested.

3. Assistive Technology Relationship to Medical Needs - The letter should explain how the requested assistive technology addresses the requesting party's medical needs or functional limitations. Generally in this context, a medical need is not a need to receive medical treatment. Rather, it is a need to compensate for a function which is limited as a result of a disability. For example, a requesting party has a medical need for a wheelchair to compensate for lost function in the lower extremities and to have a functional means of mobility.

4. Inability of Alternatives to Meet Medical Needs - Where there are alternatives, especially less expensive alternatives, available to meet the requesting party's medical needs, the letter should explain why these alternatives are not appropriate for the
requesting party. Also, the specific features which make the requested technology the necessary and appropriate alternative should be identified,

5. Ability to Use Technology - The letter should detail the requesting party's ability to use the requested assistive technology. This is especially important when the technology is motorized, electronic or particularly sophisticated. For example, when a power wheelchair is being requested, the requesting party's ability to safely operate a power wheelchair should be noted. If there was a trial with the requested device the results of this trial should be summarized.

6. Requested Assistive Technology as Community Standard- The letter should justify and explain the requesting party's need for the assistive technology. This justification should be in terms of the community standard of practice by the medical professional's peer group. The medical professional should explain that it is the standard practice or current practice in their medical profession to provide the requested assistive technology to persons with the requesting party's disability.

The letter that follows is a sample letter of medical necessity. The numbers contained in the letter correspond to the numbered elements of a letter of medical necessity.

This fact sheet was produced with funds from the Governor's Advisory Council on Technology for People with Disabilities/STAR Program funded by the National Institute on Disability and Rehabilitation Research under the Technology-Related Assistance for Individuals with Disabilities Act of 1988 as amended, P.L. 103-018. This fact sheet may be reproduced; if reproduced in its entirety, with credit to the Minnesota Disability Law Center.

The Minnesota Disability Law Center 430 First Avenue N., Suite 300 Minneapolis, MN 55401-1780 Toll Free Number: 1-800-292-4150
December 20, 1994

RE: Ms. Jane Doe
Clinic#: 4-124-109
DOB: 5/21/64

TO WHOM IT MAY CONCERN:

1Ms. Jane Doe is a 30-year-old woman with C5-6 quadriplegia related to a motor vehicle accident in 1985. Despite her significant disabilities, she had been ble to achieve independent living with the assistance of a personal care attendant. 1However, she continues to have difficulties with environmental controls within her home due to her impaired upper extremity function.

1Due to Ms. Doe's high level of injury, she is unable to use her upper extremities to control her environment. She is in need of being provided with appropriate technology for permanent use. I recommend that a voice recognition system from Advanced Speech Interface Systems, Inc., be purchased and installed in Ms. Doe's present residence. 2This company has demonstrated their equipment to us and will be able to provide ongoing service of their product.

6This system is medically necessary and is accepted among the medical community because it provides persons with C5-6 quadriplegia (like Ms. Doe) independent living to generate self-care and self-esteem as mandated under federal law. 6In order to maximize Ms. Doe's functional independence, an environmental control system is medically necessary. 3She would benefit from a 2voice-controlled system that allows her the ability to control many functions within her home such as opening doors to exit her residence in emergency situations such as a fire 4since she is currently unable to do this without the assistance of a personal care attendant. 2This system will also allow her to change the room temperature to prevent hypothermia 3since a person with C5-6 quadriplegia has difficulty maintaining a normal body temperature. 2In addition, it will provide her with the means to dial a phone by using voice commands in the event of an emergency. 3Because of her condition, this system will increase her functional capabilities and decrease her need and use for a personal care attendant.

Ms. Doe needs this system immediately. She is not going to recover nor regain any of her functional ability due to her disabling condition which occurred nine years ago. I recommend that this system be provided by Advanced Speech Interface Systems, Inc. 2This company has been in this field of expertise for ten years. They are a recognized medical assistance provider, and they are supported by the medical community. The system provided by Advanced Speech Interface Systems, Inc., will be customized to Ms. Doe's medical needs. 6Because this system will -be specifically catered towards her health needs, it represents an effective and appropriate use of program funds.

If you have any questions, please contact me.

SIGNED: _____________________

Philip Physician, M.D.

Physical Medicine and Rehabilitation Specialist

Technical Assistance Project

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Samples of Letters of Medical Necessity

http://www.doctorbach.com/letters/

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Appealing Health Insurance Denials

by Heidi Frey

Getting your medical expenses covered by your health plan can be frustrating, but a little knowledge can go a long way

The Basics

You can start by checking the following on your health plan:

Do you need a referral from your primary care physician in order to see a specialist?
Does the plan require prior authorization for a planned surgery or hospital stay?
Do you have to select a physician from a network for the charges to be fully cored?
What does your plan cover?
What does it limit or exclude?

Don’t Be Stopped By Denials

should consider appealing if:

The treatment isn’t a covered benefit, but you think the health plan should make an exception for you, or
You have support from your physician that the treatment is "medically necessary," or
The treatment is deemed by the insurance company to be experimental or investigational.

Call the company that issued the denial, armed with a file of your medical and insurance information, including your benefit plan and summary.

A customer service representative can’t overturn your denial, so ask to speak with a supervisor.

Making a Formal Appeal

Every managed care organization is required by law to have an appeal process.

Although an appeal process isn’t perfect, it’s much less of a financial and emotional burden than litigation. And your contract with the health plan may prohibit you from filing a lawsuit before filing an appeal.

When formally appealing:

First, read the appeal process guidelines in your policy. Familiarize yourself with timeline requirements.
Put your complaint in writing, including:
- Your health problems and treatment history
- How you have exhausted all other reasonable alternatives
- Physician recommendations
- Why you are an ideal candidate
- What will happen if treatment is not approved
- Support letters from your physicians
- Quotes from the benefit plan if it contains helpful language
- Medical records that support your position.
Enlist your doctor’s help. Your doctor willing to advocate for you.
Track relevant dates to ensure that your complaint is moving forward expeditiously.
Be prepared to spend a lot of time on the phone.
Keep a record of all communications, including the date and time of your conversation, the full name and title of the person with whom you spoke, and a summary of what was discussed.

Getting Help

Your state Department of Insurance (DOI) has a wealth of information, including your rights regarding health insurance, the appeals process, whom to contact regarding an appeal and a general timeline for an appeal.

You should be able to locate your state’s DOI in the White Pages’ state government section under "Insurance" or "Regulatory Agencies." Your state government’s home page should have a link to the DOI.

If you have questions regarding the mechanics of the appeals process:

If you’re in a self-insured plan, which means that your employer has direct responsibility for medical costs, you should contact someone in your employer’s human resources department for more information.
If you’re in a Medicaid managed care plan, you may have special rights in the appeal process and you should contact the State Ombudsman or Medicaid customer service.
If you’re in a commercial plan, which means that the managed care organization has direct responsibility for medical costs, the appeals process is outlined in your policy and follows state laws.

What’s Next

If the cost of the denial is enough to offset legal fees, it may be best for you to speak with an attorney who has experience with health care coverage and benefit denials.

* Link no longer available

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Internal Lymphedema People Related Pages:

How to File A Health Insurance Appeal

http://www.lymphedemapeople.com/wiki/doku.php?id=how_to_file_a_health_insurance_appeal

Insurance Codes for Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=insurance_codes_for_lymphedema

Letter of Medical Necessity

http://www.lymphedemapeople.com/wiki/doku.php?id=letter_of_medical_necessity

Directory of Insurance Commisioners

http://www.lymphedemapeople.com/thesite/lymphedema_advocacy_insurance_comm.htm

How to File a Complaint Against Your Insurance Company

http://www.lymphedemapeople.com/wiki/doku.php?id=how_to_file_a_complaint_against_your_insurance_company

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Join us as we work for lymphedema patients everywehere:

Advocates for Lymphedema

Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.

http://health.groups.yahoo.com/group/AdvocatesforLymphedema/

Subscribe:

AdvocatesforLymphedema-subscribe@yahoogroups.com

Pat O'Connor

Lymphedema People / Advocates for Lymphedema

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For information about Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema\

For Information about Lymphedema Complications

http://www.lymphedemapeople.com/wiki/doku.php?id=complications_of_lymphedema

For Lymphedema Personal Stories

http://www.lymphedemapeople.com/phpBB2/viewforum.php?f=3

For information about How to Treat a Lymphedema Wound

http://www.lymphedemapeople.com/wiki/doku.php?id=how_to_treat_a_lymphedema_wound

For information about Lymphedema Treatment

http://www.lymphedemapeople.com/wiki/doku.php?id=treatment

For information about Exercises for Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=exercises_for_lymphedema

For information on Infections Associated with Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=infections_associated_with_lymphedema

For information on Lymphedema in Children

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema_in_children

Lymphedema Glossary

http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing

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Lymphedema People - Support Groups

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Children with Lymphedema

The time has come for families, parents, caregivers to have a support group of their own. Support group for parents, families and caregivers of chilren with lymphedema. Sharing information on coping, diagnosis, treatment and prognosis. Sponsored by Lymphedema People.

http://health.groups.yahoo.com/group/childrenwithlymphedema/

Subscribe: childrenwithlymphedema-subscribe@yahoogroups.com

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Lipedema Lipodema Lipoedema

No matter how you spell it, this is another very little understood and totally frustrating conditions out there. This will be a support group for those suffering with lipedema/lipodema. A place for information, sharing experiences, exploring treatment options and coping.

Come join, be a part of the family!

http://health.groups.yahoo.com/group/lipedema_lipodema_lipoedema/?yguid=209645515

Subscribe: lipedema_lipodema_lipoedema-subscribe@yahoogroups.com

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MEN WITH LYMPHEDEMA

If you are a man with lymphedema; a man with a loved one with lymphedema who you are trying to help and understand come join us and discover what it is to be the master instead of the sufferer of lymphedema.

http://health.groups.yahoo.com/group/menwithlymphedema/

Subscribe: menwithlymphedema-subscribe@yahoogroups.com

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All About Lymphangiectasia

Support group for parents, patients, children who suffer from all forms of lymphangiectasia. This condition is caused by dilation of the lymphatics. It can affect the intestinal tract, lungs and other critical body areas.

http://health.groups.yahoo.com/group/allaboutlymphangiectasia/

Subscribe: allaboutlymphangiectasia-subscribe@yahoogroups.com

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Lymphatic Disorders Support Group @ Yahoo Groups

While we have a number of support groups for lymphedema... there is nothing out there for other lymphatic disorders. Because we have one of the most comprehensive information sites on all lymphatic disorders, I thought perhaps, it is time that one be offered.

DISCRIPTION

Information and support for rare and unusual disorders affecting the lymph system. Includes lymphangiomas, lymphatic malformations, telangiectasia, hennekam's syndrome, distichiasis, Figueroa
syndrome, ptosis syndrome, plus many more. Extensive database of information available through sister site Lymphedema People.

http://health.groups.yahoo.com/group/lymphaticdisorders/

Subscribe: lymphaticdisorders-subscribe@yahoogroups.com

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All About Lymphedema

For our Google fans, we have just created this online support group in Google Groups:

Homepage: http://groups-beta.google.com/group/All-About-Lymphedema

Group email: All-About-Lymphedema@googlegroups.com

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Lymphedema Friends

http://groups.aol.com/lymphedemafriend

If you an AOL fan and looking for a support group in AOL Groups, come and join us there.

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Lymphedema People New Wiki Pages

Have you seen our new “Wiki” pages yet? Listed below are just a sample of the more than 140 pages now listed in our Wiki section. We are also working on hundred more. Come and take a stroll!

Lymphedema Glossary

http://www.lymphedemapeople.com/wiki/doku.php?id=glossary:listing

Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=lymphedema

Arm Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=arm_lymphedema

Leg Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=leg_lymphedema

Acute Lymphedema

http://www.lymphedemapeople.com/wiki/doku.php?id=acute_lymphedema

The Lymphedema Diet

http://www.lymphedemapeople.com/wiki/doku.php?id=the_lymphedema_diet