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Insurance Denied Again

Posted by Mar on 12/16/02 at 07:10 (103260)

My insurance company (CIGNA at the time of ESWT) originally denied coverage. I filed an appeal and just got the letter that they denied it again, saying that there have not been enough studies. I can file a second appeal within a year. Anyone have any suggestions as to what I can include in this second appeal to sway them? Thanks -- Mar

Re: Insurance Denied Again

Dr. Zuckerman on 12/16/02 at 08:58 (103268)

How many studies do they need? There have been two FDA studies in the past three years. File a complaint with the State Insurance commission

Re: Insurance Denied Again

steveb on 12/16/02 at 17:23 (103321)

i just scheduled an appointment with a doctor to get Sonocur treatment here in phoenix (i've already had 3 treatments in canada 6 months ago, but could use some more). my insurance is cigna too. i was hoping they'd cover it. looks like i might be paying for it myself.

Re: Insurance Denied Again

Mar on 12/16/02 at 17:39 (103325)

Dr Z --

Do you know where I can get copies of the 2 studies? I will investigate the State Insurance Commission too. Do you think i should get a lawyer involved? Thanks -- Mar

Re: Insurance Denied Again

Scott Reeves on 12/16/02 at 17:39 (103326)

Sonocur is not FDA approved for PF - only tennis elbow. Could this be part of the problem?

Re: Insurance Denied Again

Mar on 12/16/02 at 17:40 (103327)

Steve --

Have you submitted anything to CIGNA yet? I am curious to know what they say to you. Mar

Re: Insurance Denied Again

Mar on 12/16/02 at 17:41 (103328)

Scott --

Mine was on the Dornier Epos, so that was not the problem for me. Mar

Re: Insurance Denied Again

BrianG on 12/16/02 at 18:24 (103337)

H Mar,

In your appeal did you tell them that the FDA had already done studies on the Dornier, and the Ossatron? If not, use that last appeal, and bring copies of the studies with you. I don't personally have them, but both have been listed here, try the search engine. If you can't find them here, go to the FDA web site.

Good luck
BrianG

Re: Insurance Denied Again

Dr. Zuckerman on 12/16/02 at 18:33 (103339)

I will send you a copy of the article I wrote it talks about a few studies. The one year dornier follow up is one this web site. Do a search
I would see exactly what your policy appeals process states. Very important to follow the stupid protocol for appeals. I had a patient just win an appeal from Independence Blue Shield.

Re: Insurance Denied Again

Mar on 12/16/02 at 20:47 (103355)

Yes - I told them of FDA approval and enclosed an article. I'll look for the actual studies. Thanks Mar

Re: Insurance Denied Again

Mar on 12/16/02 at 20:51 (103356)

Dr Z --

I found the article you wrote so you don;t have to send it again. It's the one you posted a couple of weeks ago, right? I had printed it out. I'll search ffor the studies too next week when I have more time. I have to read the whole appeal thing closely too when I have more time. It's pages and pages long - i guess to try to discourage people. I'm not giving up. I just want to get as much info and help on this as possible to present the best possible case. Good news about the Blue Shield appeal -- thanks for the encouragement! Mar

PS Got cam walker today on left foot -- now this should be a challenge and a half!!!

Re: Insurance Denied Again

David G. on 12/19/02 at 14:52 (103552)

I too have been denied by Oxford multiple times. I am just finishing my final draft to the State Insurance commission. Dr. Z, can you send me copies of the reports you are talking about. you sent me one already, it was color and showed the 92% success. what's the other?

Re: Insurance Denied Again

Dr. Z on 12/19/02 at 18:06 (103564)

The ossatron report. go to their site. It shows the other one year follow up afte the FDA reporting. I do have the article I wrote which shows a summary of high energy studies but they will only want the Epos and the ossatron article. If you have a problem getting if from their site let me know

Re: Insurance Denied Again

kellyc on 1/06/03 at 21:29 (104989)

Good luck with CIGNA. I have been fighting with them since Dec. 2000 when it was FDA approved. The FDA approval means NOTHING to them. They want to see a published peer review done that shows it an effective treatment. The catch is, the study has to meet their criteria of not being biased, double blind, etc. I have a stack of material a foot tall and it hasn't worked so far, in fact, I had a conversation today with a doctor that is on their technology assessment team. They don't intend to cover this based on my discussion with her and she says it's not about the money. Right.

I have had this for 10+ years, participated in the OssaTron FDA clinical trials and had great success with my left foot. I think I should just cut off my right foot, if I did it with a bread knife it might feel better than it does now!

Lordy this is SO frustrating.
Kelly

Re: Insurance Denied Again

Dr. Z on 1/06/03 at 22:29 (104997)

Hi

E-mail Dr Z at (email removed). I have a patient that told me that she got payment from Cigna for ESWT. I may be able to get the EOB for you.
I wrote an article on What Shockwave Studies Reveal . Would that help you.?

Re: Insurance Denied Again

KellyC on 1/07/03 at 07:20 (105010)

Yes, any printed material I can get will help.

Re: Insurance Denied Again

steveb on 1/09/03 at 12:29 (105164)

i couldn't get an appointment until Feb 5, 2003. so, i'll have to wait until then find out if they'll cover it.

Re: Insurance Denied Again

Dr. Zuckerman on 12/16/02 at 08:58 (103268)

How many studies do they need? There have been two FDA studies in the past three years. File a complaint with the State Insurance commission

Re: Insurance Denied Again

steveb on 12/16/02 at 17:23 (103321)

i just scheduled an appointment with a doctor to get Sonocur treatment here in phoenix (i've already had 3 treatments in canada 6 months ago, but could use some more). my insurance is cigna too. i was hoping they'd cover it. looks like i might be paying for it myself.

Re: Insurance Denied Again

Mar on 12/16/02 at 17:39 (103325)

Dr Z --

Do you know where I can get copies of the 2 studies? I will investigate the State Insurance Commission too. Do you think i should get a lawyer involved? Thanks -- Mar

Re: Insurance Denied Again

Scott Reeves on 12/16/02 at 17:39 (103326)

Sonocur is not FDA approved for PF - only tennis elbow. Could this be part of the problem?

Re: Insurance Denied Again

Mar on 12/16/02 at 17:40 (103327)

Steve --

Have you submitted anything to CIGNA yet? I am curious to know what they say to you. Mar

Re: Insurance Denied Again

Mar on 12/16/02 at 17:41 (103328)

Scott --

Mine was on the Dornier Epos, so that was not the problem for me. Mar

Re: Insurance Denied Again

BrianG on 12/16/02 at 18:24 (103337)

H Mar,

In your appeal did you tell them that the FDA had already done studies on the Dornier, and the Ossatron? If not, use that last appeal, and bring copies of the studies with you. I don't personally have them, but both have been listed here, try the search engine. If you can't find them here, go to the FDA web site.

Good luck
BrianG

Re: Insurance Denied Again

Dr. Zuckerman on 12/16/02 at 18:33 (103339)

I will send you a copy of the article I wrote it talks about a few studies. The one year dornier follow up is one this web site. Do a search
I would see exactly what your policy appeals process states. Very important to follow the stupid protocol for appeals. I had a patient just win an appeal from Independence Blue Shield.

Re: Insurance Denied Again

Mar on 12/16/02 at 20:47 (103355)

Yes - I told them of FDA approval and enclosed an article. I'll look for the actual studies. Thanks Mar

Re: Insurance Denied Again

Mar on 12/16/02 at 20:51 (103356)

Dr Z --

I found the article you wrote so you don;t have to send it again. It's the one you posted a couple of weeks ago, right? I had printed it out. I'll search ffor the studies too next week when I have more time. I have to read the whole appeal thing closely too when I have more time. It's pages and pages long - i guess to try to discourage people. I'm not giving up. I just want to get as much info and help on this as possible to present the best possible case. Good news about the Blue Shield appeal -- thanks for the encouragement! Mar

PS Got cam walker today on left foot -- now this should be a challenge and a half!!!

Re: Insurance Denied Again

David G. on 12/19/02 at 14:52 (103552)

I too have been denied by Oxford multiple times. I am just finishing my final draft to the State Insurance commission. Dr. Z, can you send me copies of the reports you are talking about. you sent me one already, it was color and showed the 92% success. what's the other?

Re: Insurance Denied Again

Dr. Z on 12/19/02 at 18:06 (103564)

The ossatron report. go to their site. It shows the other one year follow up afte the FDA reporting. I do have the article I wrote which shows a summary of high energy studies but they will only want the Epos and the ossatron article. If you have a problem getting if from their site let me know

Re: Insurance Denied Again

kellyc on 1/06/03 at 21:29 (104989)

Good luck with CIGNA. I have been fighting with them since Dec. 2000 when it was FDA approved. The FDA approval means NOTHING to them. They want to see a published peer review done that shows it an effective treatment. The catch is, the study has to meet their criteria of not being biased, double blind, etc. I have a stack of material a foot tall and it hasn't worked so far, in fact, I had a conversation today with a doctor that is on their technology assessment team. They don't intend to cover this based on my discussion with her and she says it's not about the money. Right.

I have had this for 10+ years, participated in the OssaTron FDA clinical trials and had great success with my left foot. I think I should just cut off my right foot, if I did it with a bread knife it might feel better than it does now!

Lordy this is SO frustrating.
Kelly

Re: Insurance Denied Again

Dr. Z on 1/06/03 at 22:29 (104997)

Hi

E-mail Dr Z at (email removed). I have a patient that told me that she got payment from Cigna for ESWT. I may be able to get the EOB for you.
I wrote an article on What Shockwave Studies Reveal . Would that help you.?

Re: Insurance Denied Again

KellyC on 1/07/03 at 07:20 (105010)

Yes, any printed material I can get will help.

Re: Insurance Denied Again

steveb on 1/09/03 at 12:29 (105164)

i couldn't get an appointment until Feb 5, 2003. so, i'll have to wait until then find out if they'll cover it.