Ginevra Posted June 21, 2019 Share Posted June 21, 2019 (edited) I have been going to PT for five weeks because of scar tissue healing poorly from breast cancer surgery. Well, I got the letter today from CareFirst that they are denying coverage for this, saying it is not scientifically verifiable that the physical therapy will resolve the problem. 🤬 Gee, thanks, CareFirst; so gladd we’re paying $25,000 in premiums every year! What do I do about this? I don’t know if I call PT and ask them what I can do? It seems likely they have seen denials before. Ugggghhhh! Honestly, it’s about the twelfth thing around here that’s gone to sh!t here lately; I have had other fun things like a fridge (brand new) that broke on Easter and Sears just finally fixed yesterday; my air conditioning unit just gave up the ghost and that costs $10,000 to replace; my daughter’s car got hit while she was at work, doing $1,700 worth of damage...I just wish I didn’t have to deal with all this stuff! And now I have to somehow see if I can move heaven and earth for the health i surance company to actually DO what it is we pay through the nose for them to do. Please, if you don’t have something nice to say, don’t reply. ETA: Actually...as I am looking at this right now, I think it may be denying one particular thing they did, which the therapist did warn me was sometimes rejected by insurance. So! I may be jumping the gun on thinking this letter means they are denying all the PT. I was sort of on alert because I have not gotten any Explanation of Benefits claim coverage forms for any of the PT sessions yet and so I was already wondering if they are covering PT. Edited June 21, 2019 by Quill Additional information coming to light 11 Quote Link to comment Share on other sites More sharing options...
hippiemamato3 Posted June 21, 2019 Share Posted June 21, 2019 I'm sorry for all the stress you are experiencing. I hate insurance companies - I feel your pain! 2 Quote Link to comment Share on other sites More sharing options...
MercyA Posted June 21, 2019 Share Posted June 21, 2019 Hugs to you, Quill. ❤️ As for you, CareFirst, I'm shaking my fist at you!!! 😡Grrr. I would maybe try calling whomever ordered the PT for you and see if they can tell CareFirst that it's medically necessary. Please keep us posted! 4 Quote Link to comment Share on other sites More sharing options...
scholastica Posted June 21, 2019 Share Posted June 21, 2019 I would definitely contact the PT place and see what they suggest. They may be able to word it differently to get it approved. There's no doubt they've seen it before. I hate that there is now another layer of company to go through to get care. 2 Quote Link to comment Share on other sites More sharing options...
Stacia Posted June 21, 2019 Share Posted June 21, 2019 Hugs, Quill. I would also call the insurance company and ask them to cover it. Years ago, my sister worked at a hospital, negotiating their contracts with insurance companies. Her take is that insurance companies will deny anything they think they can get away with because it saves them money to not pay out. A majority of people won't call so it works to the insurance company's benefit. But if you call and request a reassessment and explain why it's medically necessary, they may reconsider and cover at least some of the cost. More hugs. It is such a pain to deal with all this kind of crap. At least give yourself a restful and nice weekend if you can. 2 Quote Link to comment Share on other sites More sharing options...
itsheresomewhere Posted June 21, 2019 Share Posted June 21, 2019 (edited) PT just gave DH a bunch of exercises to do at home to help the scar tissue using a muscle roller. It seems to be working well for him as it is not extremely tight now. Wonder if your PT might be able to give you some? In anyway was this area was affected muscle wise with the surgery that the PT could help get the insurance company to pay for it. Is massage therapy covered on your plan by any chance? Massage therapy is good for scar tissue issues, too. Call the insurance company and file an appeal after talking to PT. Usually when you file the appeal, they end up paying. Make sure to describe in great detail how much the scar tissue issue is affecting your life right now on the appeal paper work. Edited June 21, 2019 by itsheresomewhere 1 Quote Link to comment Share on other sites More sharing options...
May Posted June 21, 2019 Share Posted June 21, 2019 I’m so sorry😢 That’s a lot of crap on your plate🌺 1 Quote Link to comment Share on other sites More sharing options...
mumto2 Posted June 21, 2019 Share Posted June 21, 2019 I’m sorry, hugs. I would call the PT and let them know. Years ago when my mom had her first BC surgery the PT was able to get coverage for lymphadema massages which I guess is hard. Had to resubmit a few times. 1 Quote Link to comment Share on other sites More sharing options...
mmasc Posted June 21, 2019 Share Posted June 21, 2019 That just plain sucks. I’m sorry. I’d probably start with the PT folks asking them if they have any suggestions on how to get it covered...it could be a coding thing, or maybe a specific ‘medically necessary’ form for your doctor to fill out, or something hopefully that will get this covered for you! What a pain in the *** to handle though. 😞 1 Quote Link to comment Share on other sites More sharing options...
kiwik Posted June 21, 2019 Share Posted June 21, 2019 I know it is the last thing you need so hugs. I don't know anything about medical insurance but I know with other things denying can be a "suck it and see approach" and if you push back they may cave. Most people won't have the energy to push back. 1 Quote Link to comment Share on other sites More sharing options...
Arcadia Posted June 21, 2019 Share Posted June 21, 2019 The PT’s medical coding specialist might know what to do. To get my lung X-ray and lung CT scan approved, my oncologist asked the medical coding specialist for what codes to put in. The lung CT scan approval came a week later, the lung X-ray approval was within hours. My oncologist says it is about putting more relevant medical billing codes than needed and hopefully one of the codes work to get the approval we need. *hugs* 1 1 Quote Link to comment Share on other sites More sharing options...
Valley Girl Posted June 21, 2019 Share Posted June 21, 2019 (edited) Aww, Quill, that stinks when you can't seem to catch a break. A couple of ideas here. Was the PT facility in network? I know every insurance company and policy is different, but I'd find out if a predetermination/preauthorization was required. If it is and it was submitted and given a thumbs up, that may give you some leverage with the insurance company. (I never take the word of the first person I talk to. I usually try for best of 2 out of 3 because different people can give different answers.) Also find out who was responsible under the terms of the contract (your contract AND the providers contract) for applying for the predetermination/preauthorization. I was recently told that if the contract says the facility is supposed to check it before providing service and they don't, that the problem is on them then and not you, which I interpreted and meaning the patient might not be on the hook for things. Now that was my insurance. It may not be an across-the-board thing. But it's worth checking out. Good luck. Edited June 21, 2019 by Valley Girl typos 1 Quote Link to comment Share on other sites More sharing options...
ktgrok Posted June 21, 2019 Share Posted June 21, 2019 You can also file a complaint with your state insurance commissioner. They often have the whole process online. I've had GREAT success with this, with messed up claims magically getting fixed when I filed a complaint and the state opened an investigation. 3 Quote Link to comment Share on other sites More sharing options...
Guest Posted June 21, 2019 Share Posted June 21, 2019 25 minutes ago, Valley Girl said: Aww, Quill, that stinks when you can't seem to catch a break. A couple of ideas here. Was the PT facility in network? I know every insurance company and policy is different, but I'd find out if a predetermination/preauthorization was required. If it is and it was submitted and given a thumbs up, that may give you some leverage with the insurance company. (I never take the word of the first person I talk to. I usually try for best of 2 out of 3 because different people can give different answers.) Also find out who was responsible under the terms of the contract (your contract AND the providers contract) for applying for the predetermination/preauthorization. I was recently told that if the contract says the facility is supposed to check it before providing service and they don't, that the problem is on them then and not you, which I interpreted and meaning the patient might not be on the hook for things. Now that was my insurance. It may not be an across-the-board thing. But it's worth checking out. Good luck. The PT facility is directly affiliated with the breast cancer center where I was treated and I was referred to PT by my surgeon. So 🤷🏻♀️ I can’t see how they would deny it on that basis. The letter says, “According to the current CareFirst Blue Cross BlueShield Medical Policy 2.01.062, bioimpedance for assessment of lymphedema is considered experimental/investigational and does not meet TEC criteria #2-5.” Actually...as I am looking at this right now, I think it may be denying one particular thing they did, which the therapist did warn me was sometimes rejected by insurance. So! I may be jumping the gun on thinking this letter means they are denying all the PT. I was sort of on alert because I have not gotten any Explanation of Benefits claim coverage forms for any of the PT sessions yet and so I was already wondering if they are covering PT. I’m going to amend my OP because I think I misunderstood it. 2 Quote Link to comment Share on other sites More sharing options...
PrincessMommy Posted June 21, 2019 Share Posted June 21, 2019 Aww.. Quill... that is a lot of craptastic stuff happening at once. hugs... I see your update and I hope it's something simple like one thing. Crossing my fingers for you. Hope the A/C fix isn't as much as you fear. 2 Quote Link to comment Share on other sites More sharing options...
Arcadia Posted June 21, 2019 Share Posted June 21, 2019 17 minutes ago, Quill said: The PT facility is directly affiliated with the breast cancer center where I was treated and I was referred to PT by my surgeon. All my breast cancer related services are done by Stanford Healthcare but BCBS still needs pre-approval for most services. My BCBS reset in April 2019 and we are already maxed out of pocket for the insurance year. Quote Link to comment Share on other sites More sharing options...
Guest Posted June 22, 2019 Share Posted June 22, 2019 6 minutes ago, Arcadia said: All my breast cancer related services are done by Stanford Healthcare but BCBS still needs pre-approval for most services. My BCBS reset in April 2019 and we are already maxed out of pocket for the insurance year. Mine resets Jan 1st and I did not get the benefit of having fully paid my deductable. It didn’t get paid up before the year ended this year and it hasn’t been fully paid out yet this year, either. Kind of annoying because I wanted to take advantage of that and have dh go do some stuff that will be fully covered, like dermatology screening and some other stuff. Quote Link to comment Share on other sites More sharing options...
scholastica Posted June 22, 2019 Share Posted June 22, 2019 32 minutes ago, Quill said: The PT facility is directly affiliated with the breast cancer center where I was treated and I was referred to PT by my surgeon. So 🤷🏻♀️ I can’t see how they would deny it on that basis. The letter says, “According to the current CareFirst Blue Cross BlueShield Medical Policy 2.01.062, bioimpedance for assessment of lymphedema is considered experimental/investigational and does not meet TEC criteria #2-5.” Actually...as I am looking at this right now, I think it may be denying one particular thing they did, which the therapist did warn me was sometimes rejected by insurance. So! I may be jumping the gun on thinking this letter means they are denying all the PT. I was sort of on alert because I have not gotten any Explanation of Benefits claim coverage forms for any of the PT sessions yet and so I was already wondering if they are covering PT. I’m going to amend my OP because I think I misunderstood it. I hope this is the case, I’m sorry so much has gone wrong lately. We had a year like that a few years ago. First the washer, then my car, then the drier, then the garage door. Dh had just started a new job and we were joking that it was the job’s fault. 1 Quote Link to comment Share on other sites More sharing options...
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