Insurance denied coverage for scleral lens

[saralynn143]

Now for an appeal. Sigh.

[CHD63]

Oh my!  Would they rather pay later for a corneal transplant?!?!?  Unbelievable.  Just another instance of denying, hoping the patient will accept their fate and not appeal! 

Clarice

[saralynn143]

I plan to appeal based on the fact that I am only asking for one lens, used as a prosthetic due to a non-functioning eyelid.

This is a much less expensive option for them than the Boston Foundation for Sight PROSE lens which is usually covered.

We'll see. Meanwhile the optometrist office would like to be paid.

[saralynn143]

To Whom it May Concern:

I wish to appeal your decision on the enclosed Claim Control Number: [deleted].

[deleted] has denied coverage for a scleral contact lens for my left eye. I do not need it to improve my eyesight; however as a result of facial paralysis complications following a microvascular decompression surgery for hemifacial spasm in 2008, my left eye does not tear properly and the eyelid does not blink. This causes an extreme dry eye condition. Until I was fitted with a scleral lens, I was forced to apply an ophthalmic ointment to the eye around the clock. This helped to avoid corneal damage, but caused blurry vision.

The design of a scleral lens keeps a layer of saline on the surface of the eye, returning clear vision while protecting the cornea.  In my case, it not only improves the quality of my health, but of my life. It is mentally exhausting to compensate for half-blurry vision day after day.

There are multiple benefits to the lens: elimination of eye pain, restoration of clear vision, reduced risk of corneal abrasion and ulceration, and reduced risk of injury or accident due to blurry vision or mental fatigue.

I am requesting coverage for the lens under Section 45 of Covered Medical Benefits as a prosthetic device for a non-functional eyelid. My lens is similar in nature to the Boston Foundation for Sight PROSE lens, which is considered to be a prosthetic device. However I chose to work with a local optometrist because it is a much less expensive option that also does not require long-distance travel and a lengthy fitting process.

This request applies only to the left side scleral lens and fitting. I understand that eyeglasses or a contact lens for my right eye would not be covered under our policy.

Thank you for considering this request.

[CHD63]

Sounds good to me, Sara!

I had to fight for insurance coverage many years ago and went through the entire appeal process.  Finally, at the top level, it was covered, but not without great hassle on my part.  I really resented having to do all of it when, like yours, it was a no-brainer issue to begin with!!!

Good luck!

Clarice

[Jill Marie]

Hi Saralynn,

The appeal letter looks good to me too!  As you know my Insurance company approved my appeal, then I got a letter saying that the cost of the lens was going on my deductible because it was billed out of network.  All optical companies are out of network because they don't cover contact lenses or glasses.  I told my eye doctor about it, she said we will bill the next lens through the doctor office, I said lets bill this one through the doctor office NOW!  I haven't had them do it yet because I have been dealing with the ulcerated cornea but I will call the office this week and tell them to re-bill the lens.  I haven't paid for the lens because I know they won't help me get the billing right if I have paid for it.  I got my lens in January and they haven't sent the bill to collection yet because I have kept in contact with them and let them know I'm working with my Insurance company.  Good luck with your appeal, Jill Marie

[nancyann]

WHOO HOO FOR ME!! My eye doc went before a panel of 5 (telephonic) on a 2nd level appeal & they reversed their denial: I'll be paid the cost for my scleral lens!! Thank you so much Jill Marie: I wouldn't have fought for this had it not been for you! You taught me not to give up & you were right!! You are a trail blazer!!  How could anyone say the scleral lens is not medically necessary in our case?  THANK YOU THANK YOU THANK YOU JILL MARIE~

[saralynn143]

So very glad to hear that, Nancy. I'm still awaiting the decision on my appeal.

[nancyann]

Hang in there Sara: I was expecting another denial, & I was ready to contact the Florida Insurance Commission after exhausting appeals.
I think b/c I also still wear prescription glasses, they couldn't consider this a contact lens for vision.

[saralynn143]

STILL waiting on the appeal process. The insurance company called me this week requesting a 30-day extension. The very nice woman that I spoke with said that they had twice requested my medical records from the optometrist. I told her I had an appointment two days later and I would ask . . . at my visit the doctor told me he was working on it and would submit it by the end of the week.

Meanwhile I had to pay the bill and will be reimbursed if the appeal comes through. If it does, I sure hope he is not as late with refunds as he is with medical records.

[Jill Marie]

Hi Sara & Nancyann,
 
We are all trail blazers, looking forward to the day when we read on here that someone got the scleral lens or a similar lens and the Insurance company paid for it in a "blink" of an eye and covered all or most of the cost.  It is obviously going to take time for eye doctors and Insurance companies to realize how much the lens is needed.  At my last appointment my lens eye doctor told me to come back in 6 months and to please see my old regular eye doctor for my yearly exam so I could show him how much my eye has improved so he can help his other patients with dry eye issues.  I'm really looking forward to doing that! 

As for the Insurance companies it will take time for the eye doctors and patients to help change the way the Insurance companies pay for medically necessary lenses.  One Insurance company will approve a lens then another company will look at what that company did and eventually, hopefully most Insurance companies will and do it for most or all of the cost of the lens. 

Hope you win your appeal Sara, for you and those to follow!  Jill

[saralynn143]

Grrrr. I called the insurance company yesterday to ask whether they had the info needed from the eye doc. Nope. So I called the office to ask that they submit asap. Of course I have already paid them so it's not nearly as important to them. Except that I will change practitioners if they don't follow through.

[Jill Marie]

I like your strategy, hope you don't have to go through with changing doctors, it's a hassle but at least you will have made your point.  Would like to think that they would get the Insurance billing done for you so they could help pave the way for others to get the lens too! 

I still haven't paid for my  lens, I keep calling them and they keep telling me they are working on the rebilling.  My eye doctor is very supportive of my getting the lens paid for as she has several people using the lens and would like to see more people getting the relief I have.  She had a patient recently that had to have the eye removed and she doesn't want that to happen again. 

Keep us posted, Jill

[saralynn143]

The assistant at the optometrist's office just called to let me know they had submitted the doctor's report. That's 28 days into a 30-day extension.

[saralynn143]

Received a letter today upholding the denial of payment for my scleral lens. I have 60 days to file a second appeal.