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Has anyone won an appeal w/ insurance company?

Posted by Carmel M on 2/20/02 at 09:00 (074384)

I just found out that my insurance company denied ESWT because it is 'investigational and experimental.' I'm done crying and am frustrated and mad now. Has anyone successfully won an appeal with their insurance company? Is it worth the effort or should I look into going to Canada? I have some info from Bayshore Clinic, but has anyone had it done somewhere else in Canada?

I would sure appreciate any advice or suggestions. I'm going on three years of pain now and I was really looking forward to doing more with my children this summer.

Thanks.
Carmel

Re: Has anyone won an appeal w/ insurance company?

Maggie L. on 2/20/02 at 14:14 (074410)

This may or may not help, but my Podiatrist said that since ESWT is FDA approved it is no longer considered experimental. Maybe they don't know that it's been approved? They may be turning you down for other reasons, of course, (see my posting from yesterday). You and I may be in the same Appeals boat. Tonight I am off to read the fine print in my policy. I hope we both have success!

Re: Has anyone won an appeal w/ insurance company?

Carmel M on 2/20/02 at 17:11 (074430)

Thanks for your reply, Maggie. I was thinking the same thing, that maybe they don't know it's been FDA approved. I had hoped they knew because it would make me wonder just what kind of insurance company doesn't know stuff like that!!! Anyway, I'm not giving up hope and with the Doctor's help I'm going to appeal.

I think I'll take your advice and read the fine print in my insurance policy. Good luck and let's keep each other posted.

Carmel

Re: Has anyone won an appeal w/ insurance company?

Karen K. on 2/21/02 at 08:19 (074495)

I'm in the middle of the appeals process with my ins. co. Actually , I'm towards the end. My initial appeal, a letter pleading my case, was denied but my appeals coordinator sounded optimistic as she told me the next step is to stand in front of the board of appeals. It consists of doctors and a panel of my peers who will go over my case and make a decision within ten days. I meet with the board March 1. I hope, by pursuing this appeal, I can get coverage and do my part to help push the ins. co. to approve ESWT for all.

I did have one treatment in Canada with Dr. Galea in Toronto. I highly recommend him. The first treatment did wonders for me. Like other people with really bad cases of PF I do need another treatment.

Go for the appeals process. It couldn't hurt and it just might help.
Good Luck!
KK

Re: I won, for an MRI

BrianG on 2/21/02 at 21:12 (074610)

Hi Karen,

I had to go before the appeals board at my HMO, just to get an MRI of my foot. I took my time, and wrote out my entire statement. They had no trouble with me reading it from the paper. I think it's a good idea, as I didn't leave anything out. Of course they will go around the table, and everyone will get to ask some questions (not all of them will be addressed to you). I found it pretty intimidating, as they had some heavy weights. But, I held my ground, and I won. Good luck, you can do it !!

BrianG

Re: I won, for an MRI

Karen K. on 2/22/02 at 09:55 (074679)

Congrats Brian!

I did have an MRI and it was paid for without appeal. I personally feel an MRI is a waste of time. They found no thickening of my fascia But, I still had great results with ESWT.

Thanks for the support!

Karen

Re: I won, for an MRI

BrianG on 2/22/02 at 22:38 (074773)

Hi Karen,

Thats about what they found with my MRI also. I just couldn't believe a 'little inflamation' was causing my chronic pain. I was convinced it had to have been something terrible, like bone cancer, or something. So, it's 8 years later, and the original diagnosis stands, PF :*(

Good luck
BrianG

Re: Has anyone won an appeal w/ insurance company?

DeDe A on 2/25/02 at 00:02 (074963)

I don't mean to change the subject, but, how long did it take you to heal from your first ESWT? I just had mine done 3 1/2 weeks ago and I am having a time.

Re: I won, for an MRI

john h on 2/25/02 at 09:35 (074984)

Brain that little bit of inflamation could be causing the fascia to press on the Baxter nerve partner.

Re: Has anyone won an appeal w/ insurance company?

Karen K. on 3/01/02 at 09:27 (075371)

It took about 12 weeks.

Keep the hope.
KK

Re: Has anyone won an appeal w/ insurance company?

Maggie L. on 2/20/02 at 14:14 (074410)

This may or may not help, but my Podiatrist said that since ESWT is FDA approved it is no longer considered experimental. Maybe they don't know that it's been approved? They may be turning you down for other reasons, of course, (see my posting from yesterday). You and I may be in the same Appeals boat. Tonight I am off to read the fine print in my policy. I hope we both have success!

Re: Has anyone won an appeal w/ insurance company?

Carmel M on 2/20/02 at 17:11 (074430)

Thanks for your reply, Maggie. I was thinking the same thing, that maybe they don't know it's been FDA approved. I had hoped they knew because it would make me wonder just what kind of insurance company doesn't know stuff like that!!! Anyway, I'm not giving up hope and with the Doctor's help I'm going to appeal.

I think I'll take your advice and read the fine print in my insurance policy. Good luck and let's keep each other posted.

Carmel

Re: Has anyone won an appeal w/ insurance company?

Karen K. on 2/21/02 at 08:19 (074495)

I'm in the middle of the appeals process with my ins. co. Actually , I'm towards the end. My initial appeal, a letter pleading my case, was denied but my appeals coordinator sounded optimistic as she told me the next step is to stand in front of the board of appeals. It consists of doctors and a panel of my peers who will go over my case and make a decision within ten days. I meet with the board March 1. I hope, by pursuing this appeal, I can get coverage and do my part to help push the ins. co. to approve ESWT for all.

I did have one treatment in Canada with Dr. Galea in Toronto. I highly recommend him. The first treatment did wonders for me. Like other people with really bad cases of PF I do need another treatment.

Go for the appeals process. It couldn't hurt and it just might help.
Good Luck!
KK

Re: I won, for an MRI

BrianG on 2/21/02 at 21:12 (074610)

Hi Karen,

I had to go before the appeals board at my HMO, just to get an MRI of my foot. I took my time, and wrote out my entire statement. They had no trouble with me reading it from the paper. I think it's a good idea, as I didn't leave anything out. Of course they will go around the table, and everyone will get to ask some questions (not all of them will be addressed to you). I found it pretty intimidating, as they had some heavy weights. But, I held my ground, and I won. Good luck, you can do it !!

BrianG

Re: I won, for an MRI

Karen K. on 2/22/02 at 09:55 (074679)

Congrats Brian!

I did have an MRI and it was paid for without appeal. I personally feel an MRI is a waste of time. They found no thickening of my fascia But, I still had great results with ESWT.

Thanks for the support!

Karen

Re: I won, for an MRI

BrianG on 2/22/02 at 22:38 (074773)

Hi Karen,

Thats about what they found with my MRI also. I just couldn't believe a 'little inflamation' was causing my chronic pain. I was convinced it had to have been something terrible, like bone cancer, or something. So, it's 8 years later, and the original diagnosis stands, PF :*(

Good luck
BrianG

Re: Has anyone won an appeal w/ insurance company?

DeDe A on 2/25/02 at 00:02 (074963)

I don't mean to change the subject, but, how long did it take you to heal from your first ESWT? I just had mine done 3 1/2 weeks ago and I am having a time.

Re: I won, for an MRI

john h on 2/25/02 at 09:35 (074984)

Brain that little bit of inflamation could be causing the fascia to press on the Baxter nerve partner.

Re: Has anyone won an appeal w/ insurance company?

Karen K. on 3/01/02 at 09:27 (075371)

It took about 12 weeks.

Keep the hope.
KK