Hi Alisa,
I agree with Amy's comments. Ask BCBS to justify their decision that there
is a less deluxe model available that would meet the need, ask them to name
the less deluxe model they feel can be successfully used by the patient,
and if they do so, then request that they authorize a second opinion AAC
evaluation that will test the ability of the patient to in fact use the
less deluxe model they are recommending. You will likely wear them
down with logic that they cannot match and you will ultimately win this
appeal.
I would also check to see if the BCBS plan you are dealing with has medical
coverage guidelines (also called clinical policies, etc) for speech devices
as their guideline wording may help you formulate strong wording for the
appeal. If there is no clinical policy published on-line, wording in
the insurance plan's appeal instructions generally states that the member
has the right to receive a copy of the medical policy or scientific
literature that BCBS relied upon in issuing the denial. So I would have the
patient request that information for you.
I suspect they are just denying it without good reason by using policy
exclusion wording for deluxe DME items...sort of an automatic denial and
then if an appeal comes in they will actually review the information you
submitted. I find that if you continue to go through all available
levels of appeal, eventually you reach the person with the authority to
make exceptions based on documented need. Actually I think you have
already done an excellent job of justifying the appropriateness of the
device needed by this patient, and it may be as simple as continuing to
repeat the same message to BCBS through all levels of appeal.
Judie Benwick, MSH, MPH
Care Coordinator
The ALS Association, Florida Chapter
3242 Parkside Center Circle, Tampa, FL 33619
(Toll-free) 888-257-1717, ext. 112
(Jacksonville) 904-688-0886
(Fax) 904-685-5203
-----Original Message-----
From: xxxxxx@xxxxxxxxxxxxxxxxxxxx on behalf of Amy S. Goldman
Sent: Fri 4/4/2008 8:17 AM
To: xxxxxx@xxxxxxxxxxxxxxxxxxxx
Subject: Re: [Assistive Technology] insurance question
I'd ask, on what grounds are they making that judgement? are
they RECOMMENDING a 'less deluxe device' - (if so, what are
their credentials???)
As you know, avoid using the word "best" (which you used in
your email to the list, but we know you meant "least costly
medically necessary and appropriate option")!
And, thanks for reminding us all - when denied, APPEAL!
Amy
---- Original message ----
>Date: Thu, 3 Apr 2008 18:42:59 -0700 (PDT)
>From: Alisa Brownlee <xxxxxx@xxxxxxxxx>
>Subject: [Assistive Technology] insurance question
>To: ALSA Listserv <xxxxxx@xxxxxxxxxxxxxxxxxxxx>
>
> Question for the group:
>
> We recently had an AAC device denied from Blue Cross
> for one of our PALS. We are appealing this
decision
> and I was hoping someone in the group has some
> strong wording that has proven successful with
> insurance appeals that we could incorporate into the
> appeal letter.
>
> This patient is a quad with decent head control.
We
> documented that we tried the ERICA system which was
> not successful, (patient wears special bifocals and
> the camera could not capture her eye movements and
> she could not see the screen without glasses) the
> Dynawrite and scanning Lightwriter with switch
> scanning which was slow and fatiguing, and the DV5
> with headmouse which was quicker in terms of access
> versus the above devices. We documented "that
the
> Dynavox DV5 Max offered all the features she wanted
> and Mrs. XX reported it was more comfortable and
> less fatiguing to use the head mouse as opposed to
> using a switch. Using the Dynavox V Max with a
head
> mouse system, Mrs. XX was able to fully utilize all
> the features on the device. Mrs. XX was very
> successful using the headmouse system with on-screen
> keyboard display and was able to cover the entire
> quadrant of the screen. Upon successful set up
of
> the head mouse and communication device, Mrs. XX was
> able to independently utilize the Dynavox V Max
> system to communicate her needs."
>
> Blue Cross denied this device stating a "less
deluxe
> speech generating device should be sufficient to
> meet this member's basic communication needs".
> (personal note here--my husband says I should tell
> Blue Cross that smoke signals are no longer
> recognized as a sufficient communication system but
> I don't think they would get the joke)
>
> So, I am asking the group for any good wording
> because I think we did a decent job documenting that
> this was the best device for her communication
> needs. Any help will be appreciated. You can
email
> the group or me directly at
> xxxxxx@xxxxxxxxxxxxxxxxxxxx
>
> Many thanks,
> Alisa
>
>
>
> Alisa Brownlee, ATP
> Assistive Technology Specialist
> ALS (Lou Gehrig's Disease) Association, Greater
> Philadelphia Chapter
>
> Assistive Technology Consultant, ALS Association,
> National Office
> Direct Phone Number: 215-631-1877
>
>
>
>
------------------------------------------------
>
> You rock. That's why Blockbuster's offering you one
> month of Blockbuster Total Access, No Cost.
Amy S. Goldman, Associate Director
Institute on Disabilities
Temple University
CELEBRATING 10 YEARS OF PA'S ASSISTIVE TECHNOLOGY LENDING LIBRARY!
http://disabilities.temple.edu
215-204-3862 voice direct
215-204-9371 fax
toll free (in state) 800-204-PIAT (7428)(voice)
toll free (in state) 866-268-0579 (TTY)
University Services Building Suite 610
1601 North Broad Street
Philadelphia, PA 19122
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