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Insurance rejection - HELP!!

Posted by Bob C on 2/24/04 at 12:15 (145179)

My wife has been suffering from PF for over 2 years. The first podiatrist she saw said she would need surgery before he even prescribed any conservative treatments. She didn't go back to him. When the pain started to get worse she sought out another specialist. Dr. R. gave her exercises to do, suggested the ice treatments, night splints, cortisone shots, physical therpy and finally suggested ESWT. We applied to the insurance company for pre-approval and were rejected. We have appealed the rejection and were rejected again citing the Buchbinder double blind study that determined ESWT wasn't any different than a placebo. I have been told I have three options: Appeal through my employer to overturn the insurance company rejection; pay for the treatment myself and try to collect something from the insurance; talk to the doctor about alternative treatment - surgery is the only thing left isn't it? I aslo have the option of requesting an outside arbitrator to consider the traetment for insurance coverage which I will definitely do.
The PF is in both feet. My wife is in education at a year round school and on her feet all day long. She can't be away from school for 10 to 20 weeks or whatever the recovery period would be from 2 surgeries. Looking on the down side and figuring insurance will still not approve our request I'm trying to find out what the cost will be for the ESWT on both feet and if the success rate is high enough for us to go thousands of dollars into debt on the chance that ESWT will work for her. My internet research has left me just as confused about the sucess as ever.
Suggestions? Encouragement?

Re: Insurance rejection - HELP!!

Scott D. on 2/24/04 at 12:33 (145181)

Bob,

The Buchbinder study (from Australia) used a very different treatment protocol than is used in the US. This would be like taking a sports car and a minivan out for a ride at 10 MPH and determining that since they both handle about the same at that speed, they must handle the same at any speed. It is flawed in other ways as well. The only reason it has gotten so much attention is that it gives the insurance companies a reason not to have to pay. That, afterall, is their ultimate goal.

Ask your insurance company for a RELEVANT (high energy) study that has the same result. They won't be able to find one.

Re: Insurance rejection - HELP!!

Dr. Z on 2/24/04 at 12:37 (145182)

If you would tell us the name of your insurance company maybe I can give you some additional advice. Many insurance companies are using the Buchbinder study as a reason for ESWT rejection. ESWT is a great non-invasive procedure for chronic plantar fasciitis such as your wife's

Re: Insurance rejection - HELP!!

Scott D. on 2/24/04 at 13:01 (145189)

Dr. Z,

I'm guessing its Aetna/USHC.

Re: Insurance rejection - HELP!!

Dr. Z on 2/24/04 at 13:04 (145191)

That would be my guess too

Re: Where do you live

Steve G on 2/24/04 at 17:01 (145227)

Where do you live, Bob - you can get it done in Canada for a fraction of the price people often pay in the US. I live in Seattle and many people in this area travel to the Sonocur center in Vancouver. This might be something for you and your wife to look into

Re: Insurance rejection - HELP!!

Bob C on 2/25/04 at 08:25 (145288)

The insurance company is Great West. They are actually the administrator for the plan - self-insured company.

Re: Where do you live

Bob C on 2/25/04 at 08:27 (145290)

Thanks for the thought. We live in the Kansas City area. I have considered looking into treatment in Canada but I'll wait until my arbitration request is considered to do that.

Re: Insurance rejection - HELP!!

Ed Davis, DPM on 2/27/04 at 20:12 (145542)

Scott:
I just got back from a court hearing in which the Buchbinder study was brought up as evidence. Our side found 4 fundamental flaws with the study:
1)issues with how the 'blinding' was done -- something I was not familiar with; 2)use of a protocol using inadequate energy (even for low energy); 3)the fact that 50% of the individuals in the study would not qualify for such a study since they did not meet the minimum time requirment to be classified as intractable PF (at least 6 months duration); 4) the judge noted that PF is usually diagnosed and treated by podiatrists or orthopedists but Rachel Buschbinder, MD is an epidemiologist, that is, an individual who, in all liklihood has never diagnosed or treated a PF patient in her career.
Ed

Re: Insurance rejection - HELP!!

Dr. Z on 2/27/04 at 20:17 (145543)

Did you win the case?

Re: Insurance rejection - HELP!!

Ed Davis, DPM on 2/27/04 at 20:23 (145544)

Bob:
Unusual-- Great West is usually a good company to deal with. Unfortunately, most self-insured companies are governed by ERISA which insulates them from state insurance law. I would see what the appeal process is an make sure you follow it closely. Hopefully, there is a level of appeal in which a hearing is possible. I have MASSIVE amounts of information compiled on this as I am sure does Dr. Z and others. Unfortunately, you and hopefully your doctor are feisty and ready to fight for your right to appropriate medical care. Unfortunately, until we get a patients' 'bill of rights' through Congress, many a patient will be fighting for appropriate care. Write your congressman and senator about your case. Additionally, work with your company's HR dept. or HR/benefits manager to place pressure on the 'insurer.' After all, it is your company that pays the bill to Great West and, in theory, has the final say over what is covered and what is not.
Ed
Ed

Re: Insurance rejection - HELP!!

Ed Davis, DPM on 2/27/04 at 20:32 (145545)

Dr. Z:
The hearing was on Tuesday and have not had a decision from the judge yet.
Whew! I have a healthy respect for judges since we basically threw so much information at him that I honestly don't know how one man could assimilate so much stuff! The attorney for the AG's office blindsided me only once with a letter from the medical director for WA Dept. of Labor and Industries addressed to me and date last April that I had never seen. It was not a certified letter. The letter, among a number of issues, asked for a specific baseline for acceptance of new technologies include the ratio of type 1 to type 2 studies. I need to look into that area further. Anything that you have run into?
Ed

Re: Insurance rejection - HELP!!

Dr. Z on 2/27/04 at 21:13 (145547)

We have very little Great West in our area. It is possible to win a case like this. In my experience the patient has a better chance of winning after he has had the procedure done and is looking for a re-embursement from the insurance company.

Re: Insurance rejection - HELP!!

David B on 2/28/04 at 05:34 (145565)

Bob,
I would suggest her to try active release therapy otherwise know as A.R.T. This procedure is done at a chiropractor and most insurances will pay for it, plus you don't have to be out of work. Go to this link to find a doctor that provides this care http://www.activerelease.net/providers
My foot doctor told me that my insurance company WOULD pay for ESWT so I had it done then the insurance company refused to pay, the dr and company has been fighting over it. In the meanwhile ESWT did NOT help my foot one bit, actually I had 2 ESWT treatments with NO RELIEF. I wish I would have tried ART 1st cause this is helping my foot a great deal and all I pay is my copay. What is funny about this is my chiropractor told me that he has seen several patients that has tried ESWT with no relief so they come to him to fix there foot. I know most doctors probaly think chiropractors can not help fix PF and even I was skeptical but after 7 treatments my foot feels much better. Its taking me a bit longer to get all the scar tissue broke up since I had PF for a long time plus ESWT created more scar tissue. If you want more info email me I will be glad to talk to you more.

Re: Insurance rejection - HELP!!

MARK L on 2/28/04 at 18:00 (145612)

I am very curious and I'm sure everyone else on this board is also--Please tell us- what clinical diagnostic process was used to determine that the ESWT treament you had created more scar tissue in your foot??

Re: Insurance rejection - HELP!!

Lorinda N on 3/04/04 at 01:08 (145971)

Great....... LOL.... my doc just suggested trying ESTW.....and my insurance carrier is Great West..... hopefully it will be accepted....

Re: Insurance rejection - HELP!!

MARK L on 3/06/04 at 17:17 (146256)

An aquaintance who is a podiatrist and who uses a comapny that provides FDA approved ESWT in most of the states told me that they currently have a policy of not charging any patient a technical fee for the treatment if their insurance company refuses coverage. That leaves you able to negotiate a fee only with your doctor. If you want to know who they are e-mail me at <(email removed)>

Re: Insurance rejection - HELP!!

Dr. Z on 3/06/04 at 17:28 (146258)

I am also aware that the in certain states the medical board and the attorney general is investigating this type of practice. Have you heard about this yet.

Re: Insurance rejection - HELP!!

Bob C on 3/09/04 at 11:18 (146537)

I hope your pre-treatment application is approved. My wife's doctor uses a company in Florida (we are in Kansas City area) to obtain the pre-approval and handle the billing. It is a little frustrating not knowing who is communicating with whom and trying to get information from anybody is a real problem because of the new privacy laws. My wife is in so much pain and is so frustrated with the whole process she can't talk to anyone without tears. She is scheduled for ESWT on both feet on March 18th. I'll let you know how she fares and what the final result is with the insurance company.