Icing Machine not covered under plan

[lori.36]

Calling out to all Hippies.  When I had my BHR in May 2011 my doc insisted that I use the Game Ready Icing Machine.  I used a rental from the company that he recommend, but it is being denied by my health insurance.  I am having to write a letter to request a 2nd appeal on this matter.  I have all the doctors notes and I have already faxed that for round one of the appeal that got denied.  They are saying that this is a convience item, which is not covered by the plan?  Has anyone wrote a letter of some sort for this that I could copy?  Thanks

[curt]

    Mine wasn't covered either...bought the one I got at Dr. Gross's office (around $200? maybe a little more).  As much as I enjoyed it, now I have to get something else fixed so I can use it again!

Curt

[lori.36]

Okay, Here is my rough draft.  Please be honest and tell me what you think:
To whom it may concern;

I am requesting that my insurance cover the rental of the Game Ready Icing Machine.  The Game Ready icing machine was instrumental on my recovery with my Birmingham Hip Resurfacing surgery on May 11, 2011.  My surgeon, Doctor Rector prescribed the Game Ready Machine and told me that it was medically necessary for the type of surgery that I was having.  I have a letter from Doctor Rector in this packet of information.

With the most recent appeal, I am getting a reason code 37 from UMR, reason code 37 is for when the diagnosis and or procedure is not a covered expense under the limitation and exclusion provisions of my benefits plan.  I have printed that portion of my plan and including it along with this request, because I do not see where this would be deemed excluded. 

The Game Ready Icing machine provided me with much relief during my healing process.  The relief that I received from the form fitting hip sleeve, provided 360 icing and also compression to help with the swelling.  I was able to cut back on all of the pain medications, which I attribute to the Game Ready Icing Machine.  I believe that this rental is a reasonable expense for recovery of my Hip Resurfacing Surgery, which took place in May 2001.  UMR pre-certified the surgery, and paid for it.  I would really like for UMR to also pay for the rental of the Game Ready Machine.  Please let me know how I can make this possible.

[curt]

      Might also include some form of statement such as "Due to the nature of the surgical procedure, the use of the Game Ready Ice Machine, or equivialent, is commonly prescribed therapy and deemed critical by virtually all surgeons performing hip arthroplasty.  The use of such an appliance is crucial in limiting post-surgical swelling and discomfort."

     Hope it helps.

Curt

[lori.36]

Curt, Thanks I added it to the end of the 1st paragraph, it flows well there.  Thanks for your thoughts.

[hernanu]

Can't add more, very succinct and to the point, with curt's addition.

[Aerial]

I already had one from my arthroscopic surgery and BCBS paid for the unit in August 2010.  When I had my resurfacing Dr. Gross's office said BCBS will not cover it which seemed odd to me because a little over a year ago they did!  I didn't press the issue because I already had a unit.  It was invaluable to both hip surgeries, especially since I got it covered  . Strange discrepancy though. Unfortunately there are a lot of things insurance sometimes doesn't cover.  BCBS denied coverage of Lee Webb as a surgical assistant.  I had another surgery that had a surgical assistant and they covered it, who knows why.

[Aerial]

Another thing dawned on me.  Can you get a memo stating medical necessity from your doctor? 

[lori.36]

Okay letter is sent off with a packet of information.  Here is the final draft, just incase some needs it for there case:
Call# XXXXX
Claim # XXXXXX
Date:  XXXX
To whom it may concern;

I am requesting that my insurance cover the rental of the Game Ready Icing Machine.  The Game Ready icing machine was instrumental on my recovery with my Birmingham Hip Resurfacing surgery on DATE.  My surgeon, Doctor X prescribed the Game Ready Machine and told me that it was medically necessary for the type of surgery that I was having.  I have a letter from Doctor X in this packet of information.  Due to the nature of the surgical procedure, the use of the Game Ready Ice Machine, or equivalent, is commonly prescribed therapy and deemed critical by virtually all surgeons performing hip arthroplasty.  The use of such an appliance is crucial in limiting post-surgical swelling and discomfort.

With the most recent appeal, I am getting a reason code 37 from UMR, reason code 37 is for when the diagnosis and or procedure is not a covered expense under the limitation and exclusion provisions of my benefits plan.  I have printed that portion of my plan and including it along with this request, because I do not see where this would be deemed excluded. 

The Game Ready Icing machine provided me with much relief during my healing process.  The relief that I received from the form fitting hip sleeve, provided 360 icing and also compression to help with the swelling.  I was able to cut back on all of the pain medications, which I attribute to the Game Ready Icing Machine.  I believe that this rental is a reasonable expense for recovery of my Hip Resurfacing Surgery, which took place in May 2011.  UMR pre-certified the surgery, and paid for it.  I would really like for UMR to also pay for the rental of the Game Ready Machine.  Please let me know how I can make this possible.

Patient
x cell phone
xwork phone

Enclosures:
Dr. X’s Letter of Medical Necessity
Dr. X’s Clinical Notes
Dr. X’s Operative Report
Explanation of Benefit on Claim X
Limitation and Exclusions from PPO plan with UMR
Copy of Medical Card

[hernanu]

Looks good, Lori - thanks for posting that.