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BC/BS coverage of the Ossa Tron treatment

Posted by Tess M on 7/06/04 at 20:15 (154677)

After being denied twice by BC/BS for payment of the Ossa Tron treatment for chronic pf, my external appeal to the NYS Insurance Board decided in my favor. BC/BS has to pay for this 'experimental/investigational' treatment. I am gathering data to submit to the NYS Attorney General's office because a full year later, BC/BS has still refused to answer my questions about their criteria for classification of 'experimental' and/or 'standard procedure'. They have stonewalled me, and left a very bitter taste in my mouth regarding corporate America's vise grip on health care coverage.
Please, if you have been covered by a Blue Cross Blue Shield company which actually paid for the ESWT, please let me know what area, city, or state you are located in as well as the name of the BC/BS company. Your name and personal information is not necessary. Many thanks.

Re: BC/BS coverage of the Ossa Tron treatment

Dr. Z on 7/06/04 at 21:05 (154686)

IF you are talking about Empire Blue Shield they have written policy for ESWT coverage. It is six months of pain, three failed conservative treatment and the use of an FDA approved procedure. Your treating physician can obtain this information for you. Where do you live

Re: BC/BS coverage of the Ossa Tron treatment

Tess M on 7/07/04 at 17:05 (154793)

Thanks. I'm talking about Excellus BCBS in Central NY and they did not comne even remotely close to following that policy with me despite my trying about 13 different types of 'treatment' (over at least a year's time) ranging from icing to orthotic devices to night splints to ASTM physical therapy, etc. They not only denied me twice, but they have continued to refuse to answer my questions about their policy and criteria for classifying treatments as investigational vs. standard. I'm still looking for names of BCBS affiliates that have covered the costs for the Ossa Tron procedure in the U.S.

Re: BC/BS coverage of the Ossa Tron treatment

Dr. Z on 7/08/04 at 13:22 (154859)

There are many Blue Shield throughout the USA that cover ESWT . Whether a blue shield covers any treatment including ESWT depends on the LOCAL Blue Shield Policy and has nothing to do with the national policy. Sorry you are stuck with this

Re: BC/BS coverage of the Ossa Tron treatment

MonikaA on 7/08/04 at 15:08 (154868)

BCBS covered my eswt, I'm in Kansas City

Re: BC/BS coverage of the Ossa Tron treatment

MARK L on 7/10/04 at 10:20 (155041)

Empire BCBS in NY and Horizon BCBS in NJ covers the procedure

Re: BC/BS coverage of the Ossa Tron treatment

Dennis on 7/13/04 at 14:39 (155330)

I am an attorney and fellow PF sufferer. I underwent ESWT with the Ossatron and have had good results. BC denied coverage. I paid my doctor myself and have now sued BCBS on this. They are arguing that the procedure was not 'medically necessary', and support that argument with the affidavit of their in-house physician. His affidavit is pretty conclusory and doesn't really say why it wasn't medically necessary. My doctor provided an affidavit to the contrary which says that the alternative would have been more expensive surgery with a much more lengthy recovery. We are awaiting a decision by the court. I suppose that most 'new' procedures face this same 'approval curve', i.e. they deny coverage until enough folks bring enough pressure to bear until they have a change of heart. Our misfortune to be the advance guard.

Re: BC/BS coverage of the Ossa Tron treatment

Dr. Z on 7/13/04 at 14:48 (155335)

Dennis,

About five years ago I had an attorney do the same thing. They paid him 100 cents on the dollar. This has nothing to do with cost. There is a written standard of care which states that ESWT is medical necessity when the patient has had at least six months of pain and at least three failed conserative treatments. This is an FDA approved procedures which REMOVES it from the list of investigatinal and experiemental. Good luck with your case. If there is any additional information about ESWT that I can provide just e-mail DR. Z at (email removed)

Re: BC/BS coverage of the Ossa Tron treatment

Pauline on 7/14/04 at 07:56 (155370)

Dennis,
I assume you're handling your own case. Good for you. Go get them. This is the first time I haven't heard a bad word about attorneys from our resident Pods or John h. Be proud you've crossed the attorney bashing barrier that exhibits itself here at times:*

As I've often said Attorneys are darn good when you need one. Wishing you a wonderful career.