Author Topic: Insurance Coverage Denied  (Read 1638 times)

terp1974

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Insurance Coverage Denied
« on: August 08, 2018, 06:43:21 am »
I am a state government employee.  The State Health Plan does not cover hearing aids for members over the age of 21.

I have appealed to Blue Cross Blue Shield of NC twice and so did my surgeon, all to no avail.  They will not cover the surgery.

I am probably the only state government employee who has been disabled by an AN and no longer has a hearing nerve needed to wear what they consider a hearing aid.

Does anyone have experience obtaining insurance coverage after initially being denied?

My next step is to apply for a hearing before an Administrative Law Judge at the NC Office of Administrative Hearings.

Thank you

terp1974

rupert

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Re: Insurance Coverage Denied
« Reply #1 on: August 08, 2018, 07:38:17 pm »
Are you talking about BAHA?   I only ask because you mentioned surgery.   Some people have had luck with insurance covering a BAHA because  it's considered an implant or  prosthetic device.  You're missing a hearing nerve just like someone who has a missing arm or leg .  Try talking to your doc about coding it like that maybe it'll work but, some people really have a hard time with insurance about BAHA.  I don't have one but, I have Blue Cross.  I firmly believe they spend more time and effort denying claims than paying them.

CHD63

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Re: Insurance Coverage Denied
« Reply #2 on: August 09, 2018, 05:58:13 am »
Hi terp1974 .....

Unfortunately most insurance plans do not consider single sided hearing loss a disability.  My personal opinion is given the ever increasing aging population, with accompanying age-related hearing loss, insurance companies have chosen not to cover regular hearing aids.

rupert is correct that if coded correctly, insurance companies are required to consider bone-anchored devices as prosthetics (since a titanium abutment is implanted in the skull) and therefore are covered claims.  However, that involves a surgical procedure, whereas a hearing aid(s) can be used/removed as desired.

My husband is in the process of getting new hearing aids (for age-related hearing loss in both ears).  Our insurance will not cover it.  However, they did guide us to other companies who offer considerable discounts.  It would be worth it to call your insurance and ask about alternative ways to pay for a needed hearing aid.

In the meantime, it never hurts to appeal a decision with any additional documentation you can get from your medical professionals.  From my experience with other types of claims, I have been successful with appeals.

Good luck.

Clarice
Right MVD for trigeminal neuralgia, 1994, Pittsburgh, PA
Left retrosigmoid 2.6 cm AN removal, February, 2008, Duke U
Tumor regrew to 1.3 cm in February, 2011
Translab AN removal, May, 2011 at HEI, Friedman & Schwartz
Oticon Ponto Pro abutment implant at same time; processor added August, 2011

terp1974

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Re: Insurance Coverage Denied
« Reply #3 on: August 09, 2018, 12:13:24 pm »
Rupert,

Thank you for your response. I am talking about an Oticon Medical Ponto.  From the denials I have received, they don't cover anything for a member over the age of 21.  This is definitely a different spin on age discrimination for the disabled.

I spent time with the Duke Raleigh Financial Care Counselor and she called Blue Cross Blue Shield of the State Health Plan while I was in her office. Blue Cross gave her the codes to use but they ultimately denied 2 of my appeals + 1 from Duke Raleigh.

Your last sentence makes a good point. Blue Cross told us that coverage depends on the organization's insurance plan.

Thank you

Stew (2.3 cm, Translab, 2011)

terp1974

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Re: Insurance Coverage Denied
« Reply #4 on: August 09, 2018, 12:22:05 pm »
Clarice,

Thank you for your response.

After my 2 denials from the State Health Plan with Blue Cross Blue Shield plus Duke Raleigh's denial, I have been advised to petition for a hearing with the NC Office of Administrative Hearings.  I will appear before an Administrative Law Judge and the General Counsel for the NC government division that oversees the State Health Plan.  I have obtained multiple copies of the Certificate of Medical Necessity, Denials from the State Health Plan, and relevant brochures from both ANA and Oticon Medical Ponto to provide as supporting documentation.

Once Oticon Medical's website is back up (it appears to be under maintenance), I will also print out copies of information pertaining to insurance coverage.

If your husband is a veteran, he may wish to contact the Veteran's Administration about hearing aids. The VA does cover them.

Stew  (2.3 cm, Translab, 2011)