SO MAD I COULD CRY

cooker71

God I hate health insurers!!!!

Insurance company told me today they will NOT help pay for these Sure Step foot orthodics recommended by his physical therapist to stabilize his ankles and help him learn to walk faster and more correctly.

Oh, no. Only if he has "diabetes with neurological manifestations."

They cost a couple THOUSAND dollars. I could just cry.

Of course, I'm appealing the decision, but it just makes me so mad. They'll pay to help keep the dicks of old men up, but they won't pay to help my special needs child learn to walk. Makes PERFECT SENSE.

Anyone run into things like this and have any suggestions/recommendations?

duchess0727

Have you gone to an orthopedic doctor?  If not, I would see one and see if they can provide a letter of medical necessity.  I would definitely appeal the decision.  As far I can see, it is always the insurance companies first move to decline and that doesn't mean it's a final decision.  I would talk to any of your son's doctors to see if they will also provide a letter of medical necessity.  There have to be other diagnoses that qualify - see if you can get a helpful customer service person on the phone (or definitely ask the orthopedic) and see if there is another diagnosis code they can give to get them paid for. 

Also, you might look into Leap Frog inserts by Jump Start.  They also provide ankle stabilization and alignment but they are much less expensive because they are sold in sizes and not fitted to a child's specific foot. 

Good luck!

Glendi2.0

That SUCKS. I hate how insurance companies "prioritize" disabilities like that- like it's okay for him to get the orthotics if it's Diabetes-driven but not Downs?!? Isn't the end result the same?!?

I haven't had much experience fighting my insurance, so I can't offer advice, but I know lots of people have to resubmit claims under different codes? Not sure if that even makes sense in a case like this... either way, I'm sorry you have to deal with this.

andreas4dogs

I'm sorry you are going through this... Can your doctor write a letter to the insurance company these orthotics are a medical necessity? Perhaps get one from the PT and whoever you can get a letter from...

I once had to get a pediatrician to do this because the insurance would not cover a specific hearing test Gabe needed at 11 months (he wasn't babbling and they wanted to rule out any hearing issues). It would have been quite a few hundred dollars out of pocket. The insurance company was claiming they weren't covering it because it was a routine test and the ped should not have ordered it (some bs reason).

The ped wrote a very articulate letter that HE DID NOT routinely do hearing tests on babies unless there was a SIGNIFICANT concern for a hearing/ developmental issues. I was very fortunate that I won the appeal BECAUSE of this letter.

Good luck. Insurance companies suck. 

Sobachka

Would Medicaid pay for it? Is M. on Medicaid? There are waivers there that can help you get it sooner. I know that Medicaid will cover OT and ST that private insurance does not.

cooker71

He doesn't qualify for Medicaid, but just talked to our PT and she's going to call the orthodist and see if there are any other codes we can submit them under for insurance.

If not, we'll take it from there via appeals, etc. She's so awesome. She told me, "We'll get this little man walking some way or another. Don't you worry."

JaysonandKristin

I used to work for an ins. co., and I can offer this verbiage for your letter, or your personal appeal.

If your insurance company is in the practice of approving ANY Rx medication for ANY off-label use, then there should be consideration made for orthotics to assist a child with special needs with a basic function like walking even if the orthotics are routinely dispensed for diabetics.

Good luck!  Glad to hear that at least your docs are in your corner.  That helps tremendously!! 

lazysusan

Their diabetes rationale makes no sense to me.  These braces are for children with low tone and flat arches to help provide stability for walking. 

lazysusan

Low tone could be a "neurologic manifestation" to help you justify the brace...

GreenEyesinNC

Ok - here's the deal. Insurance companies don't cover "orthotics" but they cover "durable medical equipment" which includes AFO's and SMO's (ie; Suresteps). When you say "orthotics", they think what regular old people slip in their shoes for extra support. Call the orthotist, get the code for Sure steps and then call back your insurance and give them the code. I'm fairly certain you'll be pleasantly surprised....

MaxandRuby

My insurance won't cover orthotics either except in the case of diabetics.  I have a secondary insurance that will cover them but DS2 is getting his DAFO's through EI...no cost to us.  Is that a possibility if the appeals process doesn't work?

cooker71

GreenEyesinNC:

Ok - here's the deal. Insurance companies don't cover "orthotics" but they cover "durable medical equipment" which includes AFO's and SMO's (ie; Suresteps). When you say "orthotics", they think what regular old people slip in their shoes for extra support. Call the orthotist, get the code for Sure steps and then call back your insurance and give them the code. I'm fairly certain you'll be pleasantly surprised....

Actually that's what she looked it up as "durable medical equipment." And came up with the diabetes crap.

Our PT called the doctor's office today and we're going to figure out a billing code we can use to get them covered. Or some other alternative. I have faith this will be resolved somehow. 

mommy06

I am so sorry cooker.  I know the insurance battles all too well.  Hang in there ((Hugs))

makinglemonade

Insurance battles always made me cry.  Literally, I sobbed on the phone once with a company that kept denying something EVEN THOUGH IT WAS COVERED.  I wish I had advice, except that almost always they will deny because they hope you won't appeal OR because they assume you have Medicaid.  Dirty buggers, those insurance companies!!!

Good luck.  I'm sad reading through the responses thinking about all the hoops moms of special needs kids need to jump through, as if our days weren't hard enough.

Justinlove

GreenEyesinNC:

Ok - here's the deal. Insurance companies don't cover "orthotics" but they cover "durable medical equipment" which includes AFO's and SMO's (ie; Suresteps). When you say "orthotics", they think what regular old people slip in their shoes for extra support. Call the orthotist, get the code for Sure steps and then call back your insurance and give them the code. I'm fairly certain you'll be pleasantly surprised....

This is exactly right!  I have found that the vast majority of the time, the insurance issues are more based on the doctor or therapist using the wrong codes.  I googled the codes for my insurance company and now, before I get all upset if something was initially denied, I double check those codes and all but one time, the wrong code was used.

Florak8

I thought we were going to be in the same boat. But my guy at Hanger found that they would be covered as "braces". Make sure the orthotist does that. We ended up only paying about $330 out of pocket.

DS has low tone as well. GL! 

ETA: Our insurance does not cover orthotics, either. We paid OOP for DS cranial molding helmet last year. 

haleybeth81

I agree with getting a letter for medical necessity from the ortho.  I have to have one each fitting for DD#1 or else they won't cover it.  Once they got the letter from the ortho with the dx of hypotonia they haven't given me any grief and she's on her 3rd pair.  I'm sorry they're making it harder for you because I know how much it sucks to have to fight to get what your child has to have to walk.