Please Help!!Insurnace Claim Denied

iVillage Member
Registered: 09-13-2007
Please Help!!Insurnace Claim Denied
9
Wed, 06-25-2008 - 4:24pm

I am seriously hoping someone here will have some advice or insight. I got a letter in the Mail today from our Insurance Company, Blue Cross and Blue Shield (Anthem Blue Cross as its in Maine) denying payment for my sons Genetic Testing!!OMG, what do I do now. I don't have $3000, it was the microarry chip test. I had gotten an Explanation of benefits about a month ago saying they were requesting more information from the genetics office before they would pay, but I never thought they WOULDN'T pay! I mean we had the test done to try to find some answers since my son is undiagnosed, but has global delays, apraxia, hypotonia, pronated feet ect. This is what the letter said(I know its long but I hope maybe one of you will know how to fight this):

According to the terms of your health benefit plan we have completed a retrospective review of the service listed above. The medical information provided to us was reviewed by our physician reviewer. Based upon you health benefit plan, the medical information provided to us, and the review by our physician reviewer, it was determined that benefit coverage for the above listed service in not approved for the following reason(s): Presented information dose not document symptoms of a genetic disorder, risk for a late onset genetic disorder or slowly evolving genetic disorder meeting all of the following criteria: Results of biochemical tests are not applicable, uncertain or inconclusive; A specific mutation or set of mutations, has been identified, which specifically identifies the genetic disorder with a high degree of reliability; The results of the genetic test will impact the medical management of the patient with a resulting improvement in health outcomes; and testing is accompanied by genetic counseling. Based on the information provided, medical necessity can not be confirmed, as at least one of theses criteria has not been meet. This review is based on review of Anthem medical plociy GENE.00013.

Dose anyone understand this, the test is not a medical necessity, yeah in their opinion I guess its not worth finding out what is wrong with my son!!! And am I reading that right dose it say you need to know you have a genetic mutation before you test for one. Isn't that kind of the point of the test!!!! And obviously if we had found something it would have improved his treatment are they just mad his tests came back with no genetic condition. I don't understand. Help please??!! Anyone been through this, any advice on how to fight it, what to say, what the above statement means. Thank you so much I don't think I am going to sleep tonight...what are we going to do....

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iVillage Member
Registered: 03-25-2003
Wed, 06-25-2008 - 6:08pm
Appeal, appeal, appeal!!! Their criteria sound like a catch 22. You can't test if you don't know if there's a mutation, but you can't find out if there's a mutation without testing. Grrrrrr! I've never had to file a formal appeal, but I've been told many times tat often an insurance will deny the initial claim, hoping that the person won't appeal and they won't have to pay, but on appeal they'll pay. I assume the geneticist wouldn't have ordered the test if he/she didn't suspect a genetic disorder. Do they have documentation of dysmorphic features or anything like that? I would think that would be enough to warrant testing. Maybe your geneticist's office can help you with the appeal? Good luck!


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iVillage Member
Registered: 02-24-2007
Wed, 06-25-2008 - 6:41pm

Our insurance basically said the same thing.

iVillage Member
Registered: 06-25-2008
Wed, 06-25-2008 - 9:17pm

I just want you to know that you are not alone.

                            
iVillage Member
Registered: 09-13-2007
Wed, 06-25-2008 - 10:12pm
Thank You for the advice and Support!! We actually had a similar problem with my sons speech in the begging, so our therapist Diagnosed him with an "oral motor impairment" and listed Apraxia of Speech and billed it that way and they have never had a problem again. And pretty much any child with hypotonia is also going to have it in their oral area also which may show itself in drooling, an always open mouth, hard time producing the movements of tounge and jaw to make words. Maybe they can try this approach with you and they will approve it, with a more specific diagnosis. I told my therapist I didn't care if she made something up on paper, whatever would get him the services he needed.Good luck to you also.
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iVillage Member
Registered: 08-14-2005
Thu, 06-26-2008 - 12:22am

As someone else said - Appeal it - absolutely. Do you have a good relationship with your geneticist? You need to have them write a letter in response to the insurance company letter. But first, contact the insurance company and start the appeal process. There may be a fime limit - have to appeal within 30 days, for example.


Do they say which of the criteria was not met? It looks like they listed some, then says one was not met. If you know exactly their concern, it would be easier for your dr to address it.


I think that the testing was definitely justified, and I'm guessing that your Dr can word it in a way to prove that.


good luck!!


iVillage Member
Registered: 08-14-2005
Thu, 06-26-2008 - 12:29am

I just want to say also that I used to work for a health insurance company, and yes, most times customers do win their appeals. At least that's what I always heard. And I've had to appeal a couple of times for things, and always won.


And if you fight it to the end, and the worst happens, and they just won't pay, definitely contact the Dr/hospital/testing company and explain the situation and that you're going to have to pay out of pocket. If you'll notice on your explanations of benefits, how the original bill will be one amount, the insurance will pay a different amount that's less, and the rest is written off? The insurance co gets a discount, and the provider accepts the reduced payment. If you're paying out of pocket, they should be able to reduce the cost for you too. And they should also provide terms, and maybe even financial assistance.


But I can't imagine it coming to that. I'm sorry you're having to deal with this stress!


iVillage Member
Registered: 03-27-2003
Thu, 06-26-2008 - 8:19am

Hi - We just went through our second year of a very sticky appeals process.

iVillage Member
Registered: 04-09-2008
Fri, 06-27-2008 - 1:14am

I worked for an insurance company for 7 years, everything from claims analyst to the person who reviews appeals. As a Mother of two, I have been on both sides of the fence - the one having to deny a claim and the one screaming to get the claim understood and approved!!


I would really be more than happy to help you to better understand the denial letter you got and how you can go about the appeals process (it is imperative that the provider take part in this process). I just recently wrestled Blue Cross (my insurance carrier also) for my stepson's claims and it is an absolute heartache and headache. I

iVillage Member
Registered: 06-25-2008
Sat, 08-16-2008 - 12:00pm

I am sorry it has taken me a while to reply back to you.