Please Help!!Insurnace Claim Denied
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|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....