Hello all,

 

I am appealing to the group with help that our SLP and I are doing for an ALS patient. 

 

Background:  Pt. is 38 with young kids.  Very progressed and only has eye movement.  SLP and I did AAC eval and used Dynavox Eye Max and Tobii eye gaze.  Pt. did much better on Tobii and liked the larger screen and features.  SLP recommended Tobii and documented everything and why device was chosen.  Pt. has Medicare as primary and Aetna as secondary.  Secondary was charged $4,000.  

 

Aetna denied coverage and put in the denial letter: (and this is directly from the letter)

 

"Coverage for requested services by a non-participating provider has been denied for the following reason: These services are available from participating providers.  Based on the clinical rationale provided above, the coverage is denied as not medically necessary under the terms of your benefit plan.

If this member elects to use the services of the above mentioned non-participating provider without coverage approval, the member will be responsible for all bills."

 

Participating providers that can provide this service are Lingraphia (which don't provide eye gaze units) and Dynavox.

 

So question for the group--have any of you appealled insurance companies saying you must use in-network vendors?  And has anyone ever successfully won?????   Lastly, any wording help for appeal letter will be appreciated!!!!  (I know AAC Institute has info on their site too but I need more help here)

 

Thanks!

Alisa

 

 

 

Alisa Brownlee, ATP

Clinical Manager, Assistive Technology Services

ALS (Lou Gehrig's Disease) Association National Office

 and Greater Philadelphia Chapter

Direct Phone: 215-631-1877