Help w/ insurance company

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Lou82

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Hi all - Some of you may have read me post this on the yahoo! C.I. group forum.

My mom was recently approved by her doctor for a cochlea implant. She went for all the testing, the doctor set a date (August 23rd), but we just received word last week from the insurance company that they did not approve paying for my mom's surgery because not enough evidence was submitted by my mom's doctor.

This is ridiculous because without both of her hearing aids in my mom could not hear a volcano erupt - and with both aids in she can barely hear anything. She cant hold a job, cant talk on the phone, cant hear the TV etc. In short - if my mom is not qualified for this then nobody is.

Im hoping my mom's doctor failed to submit a few importance pieces of evidence to the insurance company and after she does the insurance will approve my mom. But if they still deny her then what? My mom is clearly qualified for this and I am irrate.

Any help would be greatly appreciated.
 
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Lou82 said:
Hi all - Some of you may have read me post this on the yahoo! C.I. group forum.

My mom was recently approved by her doctor for a cochlea implant. She went for all the testing, the doctor set a date (August 23rd), but we just received word last week from the insurance company that they did not approve paying for my mom's surgery because not enough evidence was submitted by my mom's doctor.

This is ridiculous because without both of her hearing aids in my mom could not hear a volcano erupt - and with both aids in she can barely hear anything. She cant hold a job, cant talk on the phone, cant hear the TV etc. In short - if my mom is not qualified for this then nobody is.

Im hoping my mom's doctor failed to submit a few importance pieces of evidence to the insurance company and after she does the insurance will approve my mom. But if they still deny her then what? My mom is clearly qualified for this and I am irrate.

Any help would be greatly appreciated.
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Wonder if she went to a ENT (Ear, Nose, Throat) doctor? My daughter in Florida had to take her baby daughter (almost 5 months old) to one to get the paperwork to show she needs HAs before they would approve them -- just my two cents worth
 
well an idear for documentation.....you could have them do the booth word discrimation testing with hearing aids, as proof that she really really desperately needs it, and isn't just wanting to upgrade....I think actually your sitution is going to be a lot more common since more and more people are opting for CIs, and b/c CIs are getting very expensive.
 
I hope the mess will be straightened out soon so your mom can get CI. I will pray for her! :)
 
The dr. who wrote the request for approval was the surgeon/ent? Did she have the tests that include the HINT sentences? My understanding is if a person can repeat less then 60% on the HINT sentences the request is usually approved. What CI center is she going to?

oh and good luck . :)
 
Did you ask the insurance company what EXACTLY they needed? Sometimes, they demand more than we know. Get a checklist or something from the insurance company, then get the information collected and prove that you met their expectations. :)
 
VamPyroX said:
Did you ask the insurance company what EXACTLY they needed? Sometimes, they demand more than we know. Get a checklist or something from the insurance company, then get the information collected and prove that you met their expectations. :)
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Good idea. Pin them down and deliver exactly as asked. It's a pain but from what I've seen on CI hear the insurance companies usually back down after pressure. They are just trying their luck.
 
First off, find out if a C.I. is specifically excluded in the ins policy. We are fighting to get my daughters other ear done. My employers policy specifically says they will not cover it.
If it is covered in the policy, all you SHOULD need is a letter from the doctor saying it is medically necessary.
In our case, we are fighting it on the grounds of necessity, even though it is excluded. If that fails, we are trying to use another portion of the policy against them. The other portion of the policy stated they will cover 100% of prosthetics. A C.I. is a prosthetic. If they still refuse, then its time to bring up the "discrimination" word.
My advice is to keep fighting! We were initially told they will not cover it. After filing our first appeal, they still said no. We have several more appeals left and we will use every one necessary to get my daughter that surgery.
The ins co simply wants to spend as little $ as possible. The more claims they reject, the less $ the spend. If you give up and walk away, they win. Make them listen and never give up the fight. Ins co. are a rolyal pain in the arse! So you must be a bigger pain in thier arse. When they realize that you will not stop and will not go away, then they might pay for it.
 
Thanks for all of the responses. I will try to answer all the questions in this post.

First, the letter we received from the insurance company stated that they could not approve my mom because there was not enough evidence in the audiometry that was submitted. How this could be I dont know, without the hearing aids in my mom cant hear anything. With the aids in she can hear very little, she cant carry on a normal conversation unless you talk to her properly. Before my mom decided to go for a C.I. two different doctors told her she would get approved for a C.I. with no problem so I dont know how she could be denied.

My mom's doctor who will perform the C.I. surgery is not an ENT, rather she is a Otolaryngologist (spelling?). She sent my mom for a CT test, an MRI and a hearing test. My mom said the day she went for the hearing test the doctor who administered it was very sick; coughing, sneezing and wiping her nose during the exam, so I am wondering that she probably screwed up some how.

Anyway, I am going to call the doctor tomorrow for the first time and get just the basics down. My father was taking care of all of this but he is going to soft so I decided to take over. I am most likely going to ask my doctor that my mom retake her hearing test, especially the speech discrimination part.

I will post again after the phone call.

Thanks again.
 
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Lou82 said:
My mom's doctor who will perform the C.I. surgery is not an ENT, rather she is a Otolaryngologist (spelling?).
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An ENT doctor is an otolaryngologist.
 
Nope....they are just a plain ol' ENT.......two words for the same thing. It's not like the diffy between a hearing aid dispenser and a real audi.
 
Lou82 said:
Yes, but arent they like a more "advanced" ent or something?
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nah and the definition for that word is: noun; the study of diseases of the ear and throat. So ENT = Ear Nose Throat which is a department in medical center or hospital.

of course there are several positions in ENT field and otolaryngologist is one of them (since this one does not do nose eh).

http://en.wikipedia.org/wiki/Otorhinolaryngology
 
Some positive news: I spoke to my mom's doctor's assistant and he told me there is nothing really be alarmed about because the piece of evidence that the insurance company was looking for was not intially submitted, but it now has and he doesnt see why the insurance company would deny my mom again.

Hope for the best..
 
Good news. Nothing like good ole fashion confusion when you least need it.

Medical insurance can be such a pain in the rear. Sometimes, you almost feel that the paperwork is the key...to the kingdom. "Sir, I realize you are hanging by a thread but please sign on the dotted line..."
 
Lou82 said:
Some positive news: I spoke to my mom's doctor's assistant and he told me there is nothing really be alarmed about because the piece of evidence that the insurance company was looking for was not intially submitted, but it now has and he doesnt see why the insurance company would deny my mom again.

Hope for the best..
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Wow that sounds very promising!! Will she still be able to hang onto the original surgery date if approved?
 
R2D2 said:
Wow that sounds very promising!! Will she still be able to hang onto the original surgery date if approved?
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I doubt it. The date is set for the 23rd and I was told we probably wont get a response from the insurance until the end of the month.
 
That was quick. We received word today that my mom has been approved!

Thank you all!
 
Lou82 said:
That was quick. We received word today that my mom has been approved!

Thank you all!
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Wow, 23rd August it is! I hope all goes well for her and she must certainly be thinking that this is meant to be.
 
I am sure it was a mistake by the insurance company, not your mom! :D I am sure you're both very happy.
 
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