BarbWV Posted November 18, 2013 Report Share Posted November 18, 2013 Hi Everyone- I am scheduled to have my first CI implant Thursday 11/21, this week... I received a call from my surgery coordinator on Friday (4pm..) saying that insurance had denied the request for the CI. Is this common (not an issue with paperwork on my end)??? My doctor said he was filing an appeal on my behalf and would have a peer to peer review with the insurance company (I think if I heard that right). He didn't cancel the surgery, so I think that means he is fairly confident that the appeal will be approved. I haven't heard back and with 48 hours to go I am driving myself crazy thinking this might not happen. Any opinions? Is this common? anything I can do? Any help or guidance would be greatly appreciated! ~Barb Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Adam Posted November 18, 2013 HearPeers Heroes Report Share Posted November 18, 2013 Barbara, First let me welcome you to hearpeers. I am very sorry that you have to deal with this so close to your surgery date. I'm sure it has got to be very frustrating. Years ago it was almost common for insurance companies to deny paying for the surgery. As more and more implants were being implanted and the criteria to be deemed a viable candidate have loosened over the years by the FDA, there was also a huge outcry from prospective implantees and their doctors. Most insurance companies approve paying for it but some still deny only to approve on appeal. Obviously we cant say for sure what will happen but I can assure you that the doctor will fight like nobodies business to make it go through. Please let us know what happens. Adam Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Sandy Posted November 19, 2013 HearPeers Heroes Report Share Posted November 19, 2013 Hi Barbara and welcome to HearPeers. I just want to give you support and let you know I will be praying that your surgery is a go. Please let us know the outcome. Quote Link to comment Share on other sites More sharing options...
Leblisa Posted November 19, 2013 Report Share Posted November 19, 2013 I'm sure you've had pre-testing by your audiologist and maybe a CT scan too, prior to scheduling the surgery. Your audi/surgeon must feel you qualify so it's probably just a numbskull at the insurance co. who doesn't really know their job or something similar. I'm sure they'll straighten it out and there's not too much you can do at this point. About 6 weeks before my scheduled date I asked to meet with the billing office people at my hospital in order to get my prior approval done and they told me they did it 4 days before the scheduled date of surgery (!). I asked what happened if it was denied and they just shrugged. Because that made me nervous, I ended up downloading my entire insurance benefits package and reading it ALL to see what it said. Mine said something like "prosthetic devices that replace a body part needed for function" was covered and I rested easy, figuring that would do it. Good luck!!!!! Quote Link to comment Share on other sites More sharing options...
BarbWV Posted November 21, 2013 Author Report Share Posted November 21, 2013 Thanks for your support everyone! Unfortunantly my Surgery was denied yesterday morning- scheduled for today... I am so frustrated at this point. My doctor has filed a physician's appeal & I am also filing a patient verbal/written appeal to go with it. The downside it takes up to 30 days for this to "process." I am doing everything I can think of to get this approved. I went to the same audiologist for 15 years before moving to Pittsburgh & he has even offered to take the time to write a letter on my behalf to submit with my appeal. I asked the insurance company what do I do in the event this appeal is denied- how long do I have to wait to submit another etc. They said they would have to call me back. If anyone knows of anything else I can do please let me know! Thanks! ~Barb Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Adam Posted November 21, 2013 HearPeers Heroes Report Share Posted November 21, 2013 Speechless! I really dont know what to say other than i'm sorry. I imagine your doctor will get it all sorted out but i cant imagine getting yourself in the frame of mind to have it done only to be denied. Try to hang in there Barbara. Maybe a MED-EL rep can get involved. Adam Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Ivana Marinac Posted November 21, 2013 HearPeers Heroes Report Share Posted November 21, 2013 At the beginning, there is a question Nr. 0 - what is their explanation? They should have some... Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Sandy Posted November 21, 2013 HearPeers Heroes Report Share Posted November 21, 2013 Barbara, I am so sorry to hear that this has happened. Hopefully, the appeal will set things right. Adams idea of involving the Med-el rep might also be worth a try. I wish you luck and please let us know how it goes. Quote Link to comment Share on other sites More sharing options...
Leblisa Posted November 22, 2013 Report Share Posted November 22, 2013 I think you need to find out: was it denied because surgically implanted prosthetic devices are not covered by your insurance plan? OR do they disagree with your surgeon/audiologist that you 'qualify' based on your hearing loss and cochlear anatomy? Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Ivana Marinac Posted November 22, 2013 HearPeers Heroes Report Share Posted November 22, 2013 I think you need to find out: was it denied because surgically implanted prosthetic devices are not covered by your insurance plan? OR do they disagree with your surgeon/audiologist that you 'qualify' based on your hearing loss and cochlear anatomy? Excellent Lisa - there is no real help without real reason. Let's roll sleeves - comfort will not solve the case. Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Adam Posted November 25, 2013 HearPeers Heroes Report Share Posted November 25, 2013 Barbara, have you heard anything on the approval process yet? Quote Link to comment Share on other sites More sharing options...
BarbWV Posted November 26, 2013 Author Report Share Posted November 26, 2013 Hi Everyone- I was denied because I am considered "boderline"- even though I meet ALL CRITERIA- straight out of the insurance approvers mouth. My insurance DOES cover this procedure there is no "covered under a different term etc.". There is even a "cochlear implant" checklist on the website under my policy. There is a physicians appeal in place that will take up to 30 days for an answer- I also filed a verbal appeal with it. I am gathering supporting documents, letters from my audio etc. in preperation for a written "Employers" appeal if the physicials appeal is denied. When I spoke to my doctor he said we will have to wait to find out the decision on the physicians appeal to know next steps. I have a "check-up" with him in January- which he said we will file under a new hearing test worst case scenerio. I am making myself trust that he knows what he is doing since he has been dealing with this for a long time- but its hard. Does it sound like I am doing the right things? My head is spinning and I get so many different answers from all around .. Thank you everyone for your support! Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Adam Posted November 26, 2013 HearPeers Heroes Report Share Posted November 26, 2013 I would also go to the FDA website and pull up the FDA criteria for approval, print it and send that as well or just forward it to them. Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Adam Posted November 26, 2013 HearPeers Heroes Report Share Posted November 26, 2013 what were your scores? Quote Link to comment Share on other sites More sharing options...
BarbWV Posted November 26, 2013 Author Report Share Posted November 26, 2013 Hi Adam- My audiogram on 10/4/13- Speech Discrimination: 8% Right 12% Left (Presentation Level 100 in both ears- sometime 105 in Right if its a male opposed to a female) Spondees: 75 Right 70 Left (not sure what this means) AzBio: 40% High Frequencies are gone in my right ear have some low still but no benefit with the assistance of a HA. Left very little high frequencies & some low- but am still able to get benefit from a HA. This surgery was for right side only Is this what you are looking for & Thank you for your insight! ~Barb Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Adam Posted November 26, 2013 HearPeers Heroes Report Share Posted November 26, 2013 Spondee words are words that have 2 syllables each pronounced with the same emphasis. Medel i believe should have some folks that can help with pushing the approval through. I am not an audiologist but your scores did not borderline to me. Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Ivana Marinac Posted November 26, 2013 HearPeers Heroes Report Share Posted November 26, 2013 In addition, I am not American (ok, just a pinch of joke) - in my practise this wouldn't be borderline at all concluding and confirming Adam's thoughts. I would gladly like to hear how they explain their conclusion about been borderline case. And you are not even bilateral - From experience, be boring to them - they have to explain every single detail. And - do not give up. Quote Link to comment Share on other sites More sharing options...
drobinson Posted November 27, 2013 Report Share Posted November 27, 2013 I was told by my Dr. that due to ObamaCare, Insurance companies are making the necessary adjustments to meet the new mandates. Hopefully this is not one of them. Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Sandy Posted November 28, 2013 HearPeers Heroes Report Share Posted November 28, 2013 That sounds very ambiguous to me (an excuse, not a reason). I would suggest that you ask for a copy of this new mandate where it says the CI is not allowed. Quote Link to comment Share on other sites More sharing options...
BarbWV Posted December 2, 2013 Author Report Share Posted December 2, 2013 Thanks Everyone! I "should" have an answer by December 19th- They said 30 days from the day they received my appeal which was Novermber 19th. I still quialify under the 2013 policy which "should" cover this since I meet all the criteria. I am hoping this isn't a stalling tactic if the citeria becomes more strict under 2014... I am crossing my fingers at this point- I have done everything I can do...Filed all necessary paperwork in their time frame etc. ~Barb Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Ivana Marinac Posted December 3, 2013 HearPeers Heroes Report Share Posted December 3, 2013 We all are crossing our fingers for you - this really isn't fair... Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Sandy Posted December 3, 2013 HearPeers Heroes Report Share Posted December 3, 2013 I don't think insurance companies operate fairly or logically. The company I deal with will pay for a hearing aid but not for the batteries. They'll pay for insulin but not the needles. Barb, I hope all goes well and this gets sorted out for you. Quote Link to comment Share on other sites More sharing options...
HearPeers Heroes Adam Posted December 3, 2013 HearPeers Heroes Report Share Posted December 3, 2013 We are believing that it will all work out BEFORE the 19th. Did you have any luck talking to MED-EL about it? If the insurance company is just stalling, maybe a little pressure would change their tune. I just cant believe in this day and age, it is not an automatic. Then again, when the mighty dollar is involved all bets are off. Quote Link to comment Share on other sites More sharing options...
BarbWV Posted December 4, 2013 Author Report Share Posted December 4, 2013 Hi Adam- When I spoke to a representative last week- she said my surgeon and I were doing everything right. If the appeal is denied they can/will step in and help if possible. Since the appeal is still processing- stepping in might hold up/confuse the process. So for now just to let the appeal play out and call them back if it is denied. I did talk to the insurance company yesterday and they received my written appeal and attached it to my verbal appeal- so for now all I can do is wait .. Fingers Crossed! Quote Link to comment Share on other sites More sharing options...
jpl2ci Posted December 4, 2013 Report Share Posted December 4, 2013 Dear fingers Crossed, aka Barbara, waiting is the hardest part. We are pulling for you and hope for the best. Quote Link to comment Share on other sites More sharing options...
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