Lymphedema and Insurance Companies
Websites with info on coverages with various insurance companies
How to Appeal an Insurance Denial
Letter of Medical Necessity
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.
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
From Bobbie SageState 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.
NLN - Draft of Insurance Appeal Letter
Lymphedema Questionnaire - Search Data Base
LymphaCare Lymphedema Pumps and ReidSleeves
- Insurance and Managed Care
Aetna - Compression Garmets
Aetna - Lymphedema Treatments
Blue Cross - Lymphedema Guidelines
example - please contact your own individual state plan
Blue Cross - Lymphadema Devices, Intermittent Pneumatic Devices, Compression Garmets
example - please contact your own individual state plan
Blue Cross Medical Coverage Guidelines
Lymphedema garments and bandages
National Patient Advocate Foundation
Insurance Reimbursement Information
The Alliance of Claims Assistance
Offers assistance in getting insurers to pay for experimental treatments, as well as other reimbursement and billing problems
National Insurance Consumer Helpline
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.
800-942-4242. 1001 Pennsylvania Avenue NW Washington, DC
Patient Advocacy Coalition
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
Patient Advocate Foundation (PAF)
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
Health Insurance Association of America (HIAA)
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 Consumerís Guide to Disability Insurance"
"The Consumerís Guide to Health Insurance"
"The Consumerís Guide to Long-Term Care Insurance"
"The Consumerís Guide to Medicare Supplement Insurance"
A Consumer Guide to Getting and Keeping
Health Insurance - State by State Consumer Guides
Has information on individual and group plans specifically for each state
COBRA (Consolidated Omnibus Budget Reconciliation Act)
Department of Labor
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 employeeís 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.
-----------------------------Policy Information Pipeline
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
there are alternatives, especially less expensive alternatives,
meet the requesting party's medical needs, the letter should explain
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
Suite 300 Minneapolis, MN 55401-1780 Toll Free Number: 1-800-292-4150
December 20, 1994
RE: Ms. Jane Doe
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.
Philip Physician, M.D.
Physical Medicine and Rehabilitation Specialist
Technical Assistance Project
Samples of Letters of Medical Necessity
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
You can start by checking the following on your health plan:
Donít Be Stopped By Denials
should consider appealing if:
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 canít 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 isnít perfect, itís 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:
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 stateís DOI in the White Pagesí state government section under "Insurance" or "Regulatory Agencies." Your state governmentís home page should have a link to the DOI.
If you have questions regarding the mechanics of the appeals process:
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
Internal Lymphedema People Related Pages:
How to File A Health Insurance Appeal
Insurance Codes for Lymphedema
Letter of Medical Necessity
Directory of Insurance Commisioners
How to File a Complaint Against Your Insurance Company
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.
Lymphedema People / Advocates for Lymphedema
For information about Lymphedema
For Information about Lymphedema Complications
For Lymphedema Personal Stories
For information about How to Treat a Lymphedema Wound
For information about Lymphedema Treatment
For information about Exercises for Lymphedema
For information on Infections Associated with Lymphedema
For information on Lymphedema in Children
Lymphedema People - Support Groups
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.
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!
MEN WITH LYMPHEDEMA
If you are a
man with lymphedema; a man with a loved one with lymphedema who you are
to help and understand come join us and discover what it is to be the
instead of the sufferer of lymphedema.
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.
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.
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.
Lymphedema People New Wiki Pages
you seen our new ďWikiĒ
pages yet? Listed
below are just a
sample of the more than 140 pages now listed in our Wiki section. We
working on hundred more. Come
take a stroll!
are not for Lymphedema
People Online Support
and Pain Management
Lymphatic Drainage (MLD) and Complex Decongestive Therapy (CDT)
Associated with Lymphedema
to Treat a Lymphedema Wound
Infections Associated with
para-aortic lymph node dissection (EPLND)
Needle Biopsy - Fine Needle Aspiration
Lymphedema Gene VEGFC
Lymphedema Gene SOX18
Home page: Lymphedema People
Page Updated: Jan. 16, 2012