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ESWT and insurance companies

Posted by Christian D on 8/23/02 at 10:24 (093318)

hi. I just had surgery (8/15) on my left foot to remove the spur. i also had the same surgery done over a year ago for my right foot and the spur grew back (bigger too). my doctor was in such shock at this that he showed his colleagues and none of them could believe it.
my doctor has tried to get the insurance company to accept the ESWT but to no avail. is there anyone else who is having trouble with this? i have aetna insurance and they flat out denied to cover the ESWT and so i had no choice but to opt for surgery. i have been on all the NSaids and i have had my fill of painful cortisone shots (within the last 4-5 yrs...i have had 5 in the left foot and 5 in the right), in which the relief sometimes lasts as long as a menial as 5 minutes. hardly worth the pain of the injection.
the second problem is the facility that was closest to me (i live in ft lauderdale/miami) apparently closed itself down?? their number was disconnected by them! i have a friend who works for the local phone company and she looked it up and said they disconnected it themselves. its probably because the insurance companies are not accepting the coverage for the ESWT.
does anyone know of a way to maybe get them to accept covering this procedure?

Re: ESWT and insurance companies

David L on 8/23/02 at 11:31 (093328)

See http://www.sonorex.com/us/company/locator_query.php?state=FL for a Sonocur location near you. I haven't heard of any insurance companies denying a claim on low energy ESWT so far. As treatment charges range in the hundreds per treatment, vs the thousands for higher energy treatments that require anesthesia, it is in the insurance companies' best interests to cover this treatment as it is a much cheaper alternative than surgery.

Re: ESWT and insurance companies

DJ on 8/23/02 at 21:22 (093374)

According to the lady I talked to at an orthopedic clinic with a sonocur, Insurance is denied everytime for this device. This machine is very new in their office and I will attempt to get insurance coverage for this device and keep the board informed how it goes.

Re: ESWT and insurance companies

Christian D on 8/24/02 at 10:03 (093402)

the OssaTron would have been the machine used by my doctor, and according to the sheet that breaks down the costs of the procedure, i would have had to had anesthesia as well. Every single patient from my doctor's office has been denied for the OssaTron. After speaking with my insurance company on many occassions tryin to tell them my plight and to try and convince them to cover the procedure, i received the formal rejection letter almost 3 months after the inital request had been sent in. Anyone else having the problems with the OssaTron approval??
I dont know much about the different components, so whats the difference between the OssaTron and Sonocur?

Re: ESWT and insurance companies

Christian D on 8/24/02 at 10:05 (093403)

as i see from the Sonocur locator in Florida, they are all under current review here, and i would have to go to Georgia anyway. I doubt my insurance company would even consider that. =/

Re: ESWT and insurance companies

Dr. Zuckerman on 8/24/02 at 18:39 (093427)

Hi

What type of insurance do you have . I maybe be able to help you and advise you. There are three main ESWT devices in the USA at this time I will make a chart and try and explain to you

Machine. Type of energy Method of shock production. FDA approved
Soncur low energy EMSE no for heel
Ossatron high sparkgap YEs
Dornier low,medium/high EMSE YEs

We use the dornier which is the only one of the machine that used ultrasound guilded to location the area where the shockwaves are directed
If is my opinion that the dornier has a better method for location of shockwaves . The FDA results for the dornier showed a 92% average reduction in pain over a one year evaluation. This study included 136 pt
who had heel pain with a duration of two years. I hope this is a start and is helpful. The ossatron is a procedure that used general or IV sedation. The dornier is a local anesthesic.

Re: ESWT and insurance companies

Christian D on 8/25/02 at 00:04 (093447)

i have aetna (HMO), but the facilities in florida (accoring to the site) are under review or something of the like. i cant afford to go out of state. =(

Re: ESWT and insurance companies

Dr. Zuckerman on 8/25/02 at 02:16 (093449)

Hi

Aetna has a national policy that still considers ESWT experimental and or investigional regardless of its FDA approval. Sorry you are not going to get approval from this company within their process. May have to either pay for this or contact your lawyer.

Re: Appeal, to the top !

BrianG on 8/25/02 at 21:22 (093526)

Everyone who gets an ESWT denial, should file an official appeal with their insurance company. Your voices will be heard!!

BrianG

Re: ESWT and insurance companies

tomc on 8/28/02 at 09:53 (093803)

Has anyone had any success with either CIGNA HMO OF NJ or Horizon HMO of NJ ??????????

Re: ESWT and insurance companies

Dr. Zuckerman on 8/29/02 at 11:21 (093875)

horizon Blue Shield yes but it depends on your policy and your coverage.but generally speaking yes

Re: Appeal, to the top !

Ed Davis, DPM on 8/30/02 at 21:22 (094034)

Also: consider writing to your state's insurance commisioner.
Ed

Re: Don't wait forever

Dr. Z on 8/30/02 at 23:05 (094042)

Do we have any ESWT sucess stories where the insurance commisioner has fored the insurance company to pay for the procedure. We have full board appeals at the insurance level where the patient has won his appeal. This took two years but the patient did win.

It is my opinion that if you need ESWT and can afford the procedure get it done and then appeal because the fight is very long and you need your two feet to stand up to them on

Re: ESWT and insurance companies

Dr. Z on 8/30/02 at 23:08 (094043)

Ask you doctor if he accepts payment plans. I know some payment plans where you have to pay every little per months. If can be done. You need a doctor who not only knows ESWT but knows insurance and knows how to help you afford ESWT Talk to your doctor

Re: ESWT and insurance companies

David L on 8/23/02 at 11:31 (093328)

See http://www.sonorex.com/us/company/locator_query.php?state=FL for a Sonocur location near you. I haven't heard of any insurance companies denying a claim on low energy ESWT so far. As treatment charges range in the hundreds per treatment, vs the thousands for higher energy treatments that require anesthesia, it is in the insurance companies' best interests to cover this treatment as it is a much cheaper alternative than surgery.

Re: ESWT and insurance companies

DJ on 8/23/02 at 21:22 (093374)

According to the lady I talked to at an orthopedic clinic with a sonocur, Insurance is denied everytime for this device. This machine is very new in their office and I will attempt to get insurance coverage for this device and keep the board informed how it goes.

Re: ESWT and insurance companies

Christian D on 8/24/02 at 10:03 (093402)

the OssaTron would have been the machine used by my doctor, and according to the sheet that breaks down the costs of the procedure, i would have had to had anesthesia as well. Every single patient from my doctor's office has been denied for the OssaTron. After speaking with my insurance company on many occassions tryin to tell them my plight and to try and convince them to cover the procedure, i received the formal rejection letter almost 3 months after the inital request had been sent in. Anyone else having the problems with the OssaTron approval??
I dont know much about the different components, so whats the difference between the OssaTron and Sonocur?

Re: ESWT and insurance companies

Christian D on 8/24/02 at 10:05 (093403)

as i see from the Sonocur locator in Florida, they are all under current review here, and i would have to go to Georgia anyway. I doubt my insurance company would even consider that. =/

Re: ESWT and insurance companies

Dr. Zuckerman on 8/24/02 at 18:39 (093427)

Hi

What type of insurance do you have . I maybe be able to help you and advise you. There are three main ESWT devices in the USA at this time I will make a chart and try and explain to you

Machine. Type of energy Method of shock production. FDA approved
Soncur low energy EMSE no for heel
Ossatron high sparkgap YEs
Dornier low,medium/high EMSE YEs

We use the dornier which is the only one of the machine that used ultrasound guilded to location the area where the shockwaves are directed
If is my opinion that the dornier has a better method for location of shockwaves . The FDA results for the dornier showed a 92% average reduction in pain over a one year evaluation. This study included 136 pt
who had heel pain with a duration of two years. I hope this is a start and is helpful. The ossatron is a procedure that used general or IV sedation. The dornier is a local anesthesic.

Re: ESWT and insurance companies

Christian D on 8/25/02 at 00:04 (093447)

i have aetna (HMO), but the facilities in florida (accoring to the site) are under review or something of the like. i cant afford to go out of state. =(

Re: ESWT and insurance companies

Dr. Zuckerman on 8/25/02 at 02:16 (093449)

Hi

Aetna has a national policy that still considers ESWT experimental and or investigional regardless of its FDA approval. Sorry you are not going to get approval from this company within their process. May have to either pay for this or contact your lawyer.

Re: Appeal, to the top !

BrianG on 8/25/02 at 21:22 (093526)

Everyone who gets an ESWT denial, should file an official appeal with their insurance company. Your voices will be heard!!

BrianG

Re: ESWT and insurance companies

tomc on 8/28/02 at 09:53 (093803)

Has anyone had any success with either CIGNA HMO OF NJ or Horizon HMO of NJ ??????????

Re: ESWT and insurance companies

Dr. Zuckerman on 8/29/02 at 11:21 (093875)

horizon Blue Shield yes but it depends on your policy and your coverage.but generally speaking yes

Re: Appeal, to the top !

Ed Davis, DPM on 8/30/02 at 21:22 (094034)

Also: consider writing to your state's insurance commisioner.
Ed

Re: Don't wait forever

Dr. Z on 8/30/02 at 23:05 (094042)

Do we have any ESWT sucess stories where the insurance commisioner has fored the insurance company to pay for the procedure. We have full board appeals at the insurance level where the patient has won his appeal. This took two years but the patient did win.

It is my opinion that if you need ESWT and can afford the procedure get it done and then appeal because the fight is very long and you need your two feet to stand up to them on

Re: ESWT and insurance companies

Dr. Z on 8/30/02 at 23:08 (094043)

Ask you doctor if he accepts payment plans. I know some payment plans where you have to pay every little per months. If can be done. You need a doctor who not only knows ESWT but knows insurance and knows how to help you afford ESWT Talk to your doctor