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Blue Shield Tech Reports

Posted by Dr. Z on 2/20/05 at 12:51 (169500)

I recently received the Blue Shield updated tech report. The committe gives their opinion and recomendation as to whethery a new tech will benefit patients. Even if a device or procedure is FDA approved doesn't mean that they will recommend the procedure or device. Alot of local Blue Shields use this information to make coverage decision.
When reading and reviewing this information I noted that the use of the new FDA approved artificial disc didn't live up to the committee's standard of acceptance. Howeve ESWT for calcific shoulder tendonitis did.
While this is good for ESWT what about patients that have the need for the new disc implant.
I have a cousin who lives on pain medication and had the disc implant and is now living a normal painfree life without drugs.

Re: Blue Shield Tech Reports

Ed Davis, DPM on 2/21/05 at 22:03 (169598)

Dr. Z:

It has become apparent that insurers have helped politicize the process in that they did not have to pay for items not FDA approved. They are going one step further assuming that they can withhold even FDA approved treatments.

Some 'truth in advertising' is called for in that the public has no way of knowing when an affliction they may encounter may or may not be covered before considering the policy. I don't like government micromanagement but this is a case where truth in advertising is a fundamental right to be expected by the public.
Ed

Re: Blue Shield Tech Reports

elvis on 2/22/05 at 15:04 (169644)

Drs. Z and Davis....Thanx for the information. I have suffered from chronic PF for 15 months now. I've tried basically every conservative treatment. My final conservative treatmnet is losing 30 lbs of weight of course along with stretching. If that doesn't work then I plan on having ESWT (Dornier Epos Ultra). I talked with Blue Shield PPO (FL) my insurer last week and asked if EWST was a covered treatment. I got put on hold and then transferred to a claim specialist only to be told that it wasn't going to be covered. I asked why and the guy told me that their 'committee' didn't deem ESWT an effective treatment. I asked if I could appeal that decision and I was told no. I would have to get the treatment, pay for it and then apply for reimbursement. If they failed to pay then I could appeal the decision. I asked if they would cover surgery and the guy said that would depend on the Blue Shiled approval process if it came to that.

The way I look at that is they have the right to refuse coverage and I have the right to go get better insurance somewhere else. I used to be a pharmacist but now am a patent lawyer so I know the system pretty well and how it works. That being said I will get the ESWT if weight lose doesn't work and I will appeal their decision. At that time I will submit all of the peer reviewed articles showing how effective ESWT is and how it could actually save time and money if done earlier in this debilitating process.

The way I was brought up, I am responsible for my wellness, health and health care. I really wonder where a large proportion of our population got the idea that the Federal Govt has that responsibility. It amazes me. If people want cradle to grave health benefits from the govt then just go to Europe, Cuba or Canada and see how their systems work. It's an unmitigated disaster as far as I'm concerned.

Re: Blue Shield Tech Reports

Leslie B on 2/22/05 at 15:36 (169648)

I agree with your comments. I had to fight to get the ESWT that I had done today. I have an HMO through Blue Cross and they are discontinuing paying for this treatment after March 1, 2005. It was a battle that I feel good about winning. I asked the doctor what, if anything, their office has said or done to the insurance companies to emphasize the validity of ESWT. He said they have tried to show them articles that prove its' value and I said they need to get patient testamonials,too. People in the US think we have such a great healthcare system, but they are sadly mistaken. It is a shame and I hope someday things will change for the better.

Leslie

Re: Blue Shield Tech Reports

Dr. Zuckerman on 2/22/05 at 15:57 (169649)

Elvis,
I still remember one of my patients that had ESWT done back in 1999 before insurance started to cover this procedure. He finally won his appeal and this started the path for ESWT coverage in my area.
I truely believe that if any of the insurance companies failed to pay for ESWT they will lose in court because the evidence just does show that it isn't effective.
There is so much high energy peer reviewed evidence proving that ESWT is safe and effective beside the FDA process which did in fact show both safety and effectivess. I have helped many patients win many appeals and bring insurance companes to the table to pay for this procedure.
Insurance hope that you won't take the time or have the time to get approval

Re: Blue Shield Tech Reports

elvis on 2/22/05 at 16:33 (169655)

Don't worry. I'll put up a good fight especially if they will pay for surgery but not ESWT. That makes no sense at all. Believe me I really don't want to pay for this out of my pocket if I don't have to. It's just that so many people today are demanding the socialist solutions to what I consider private matters. The older I get the less I want the govt involved in my life. From talking to colleaugues in Europe the urgent care is pretty acceptable under socialized medecine. When it comes to elective procedures (like ESWT) they all say it is a disaster.

Re: Elvis

Julie on 2/23/05 at 01:46 (169676)

There are certainly drawbacks to health care systems in Europe: in the UK, long waiting times for surgeries are the worst of them. But let me ask you: if you could not afford private health insurance, and needed urgent surgery for, say, cancer or a life-threatening heart condition, wouldn't you appreciate the 'pretty acceptable' option of treatment that did not bankrupt you?

And you should stop worrying about socialism. Alas, it never existed - anywhere - and certainly doesn't now. I suggest you re-frame a little, and think of the kind of health care system we have in the UK as humanitarian. Bureaucratic and imperfect, but fundamentally humanitarian.

I pray you never get so old or so poor that you genuinely need your government 'involved' in your life to get you out of serious trouble.
.

Re: Elvis

elvis on 2/23/05 at 12:27 (169707)

So you're more worried about bankruptcy than getting cancer treatment or life saving heart surgery? Wow!! You ought to be really proud of that statement. We have provisions here in the US for those circumstances and it is called Medicare and Medicaid. You're fundamentaly a socialist. I believe in capitalism. I believe in being responsible for one's own health and you believe the government is responsible and that health care should be free. My friend in London had both parent's in need of a hip replacement. That's a very common surgery here in the US readily available to seniors on Medicare. Both my friend's parents got put on the UK list for hip replacements and both died a couple of year's later before getting their hip replacement. Who has the humanitarian system?

To keep this on point ESWT is not normally paid by insurance companies. If people who elect to get ESWT anyway and apeal the 'no coverage' decision with the insurance company eventually it will be covered when the insurance companies realize that ESWT is not only an effective treatment but could save money in the long run by introducing it earlier on in the course of the chronic plantar fasciitis synfrome. Once they realize that money can be saved then they will cover it.

Good luck to you.

Re: Elvis

Julie on 2/23/05 at 14:28 (169714)

Please don't put words in my mouth, and please don't twist my words.

I hope that if you decide to have ESWT, you will succeed in getting it covered.
.

Re: Elvis

Dorothy on 2/23/05 at 15:31 (169717)

Elvis -

This is the Colonel talking. I'm going to have to get into this fight because this is a subject near and dear to my heart. However, I am going to suggest that we step away from this hot topic before you reveal yourself to be nothin' but a hound dog and we all end up in heartbreak hotel over nasty and unkind (and IMO WRONG-HEADED ) statements.

Elvis, you haven't shown yourself to be in good health for a very long time, in spite of strange sightings in Kalamazoo, so I'm not sure you should be instructing us about health care....although a good grilled peanut butter sandwich is mighty fine, no doubt about that.

Re: Blue Shield Tech Reports

vince on 2/23/05 at 18:23 (169732)

Bravo Elvis- too bad more people don't think like you do.

Re: Blue Shield Tech Reports

vince on 2/23/05 at 18:29 (169733)

and unfortunatly too many people think like Julie- they want to live with their hands in other people's pockets, weeping tears and begging for a handout because they are sloths who have refused to prepare themselve properly to stand on their own feet. No sympathy for them- if they want sympathy they should look under 's' in the dictionary.

Re: ScottR

Julie on 2/24/05 at 02:32 (169771)

Scott, please look at Vince's latest and see what you think.
.