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Author Topic: Appeal finally won!  (Read 10057 times)
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adventurer06
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« on: December 13, 2008, 09:32:35 AM »

Just wanted to drop by and give everyone an update. As some of you may know, I had a problem with Medicaid paying for care of my device ( had it over 2 years before payments were denied)  and had already lost a couple of appeals to them. I appealed once again and contacted a lawyer (though the lawyer actually hadn't had a chance yet to do anything in my case- though he was pretty sure we could win) and I  finally recieved a letter today from Medicaid approving the care for my VNS device for my depression.
The lady from the appeals department called and talked with me for an hour about my situation and why I have the device.  I also explained how they were saving money by continuing my VNS since it has worked for my depression. They put on the appeal note that since they paid for the device (in error according to them), they would pay for continuing adjustments and said I would need to fill out a notice of exception form for further treatment other then adjustments for the device. I don't know what that means in terms of getting a new battery (if its likely I will get one with the exception form), but if I have to I suppose I will do exactly what I did this time and fight it.
 To those of you have won appeals- I was wondering if any of you were told if your insurance company will pay for your replacement generator when its time? So far I have not had anymore problems with my device since the new Dr I am seeing has adjusted all of the settings, and I am really happy I can keep him. I sent out my first payment this month ( hopefully they will refund my money I paid) and was really wondering how i was going to keep up the payments. It feels like Christmas today.
Mary
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Dispatch
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« Reply #1 on: December 13, 2008, 02:20:10 PM »

:D HI adventurer06!

This is FANTASTIC news!  I am so happy to hear you won your appeal!  Merry Christmas early, 'eh!  I hope this will give you the chance to take a deep breath and enjoy your success with VNS and the Holiday Season!

I did win my appeal for explant (now they're subrogating-geesh), so I can't give you any guidance on your question...sorry.

Please stick around and keep us updated on how you are doing!

B)
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VNS for TRD implant November, 2006.  Complete device removal including coils April, 2008.

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« Reply #2 on: December 14, 2008, 05:14:16 AM »

Great news! I'm glad all your hard work finally paid off!
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MissJennie
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« Reply #3 on: December 14, 2008, 11:27:24 AM »

CONGRATS! GREAT NEWS! :D  
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« Reply #4 on: December 15, 2008, 02:04:38 AM »

Congratulations...I'm so happy that you succeeded in getting the services you need.  Every time someone "wins" it gives me a bit of a boost.

Please keep me in your thoughts...I've been battling Aetna for 18 months...they originally paid everyone except the surgeon.  When I questioned Aetna about that, they said the whole thing was a mistake and went back to the doctors/hospital and took back all their payments and refused to cover any other services related to VNS.

So, one day, my time will come!

Again, congrats on your persistance and patience in dealing with the system.

Oreo
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adventurer06
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« Reply #5 on: December 15, 2008, 10:15:55 AM »

Oreo,
I hope that your insurance company will come to their senses and approve your treatments for your VNS. I am so sorry to know that they have been putting you through this for the last 18 months. Being sick is hard enough to battle, let alone having to spend your days worrying/arguing with an insurance company. They put on my approval letter that "Upon further review, it does appear that Medicaid had previously paid for this service in error, and as such, we agree to authorize approval of your request due to a discrepency in internal procedures". I believe they said that to cover their rumps, due to the fact that I have a copy of a letter that was sent to Medicaid outlining my surgery and its costs beforehand, not to mention its pretty hard to believe someone would authorize a payment in excess of $50,000 in error. I think its ludicrous that they are not only not covering your bills for the VNS, but that they actually are going after you for payment after the fact. Have you ever contacted a lawyer regarding this? During my appeal interview I mentioned several things that I'm sure sent bells off at their office. I mentioned unnneccesary harm if my device where to malfunction (again) from thir denial to provide care, I mentioned discrimination against the mentally ill ( I have it for TRD), I mentioned the cost benefits of my VNS device working for my depression, as well as all the other treatments in the past I have tried for the depression, the fact that they originally picked up the tab for the device, and of course mentioned that I had a lawyer and was willing to pursue the matter in whatever way served my best interests. Now even though I mentioned everything above, I believe I was still nice in the way I said it, I was not rude to them. I don't know what you have all tried, and I'm no lawyer, but I would think their would be some sort of an exception somewhere for you in your case. Don't give up hope- keep fighting.
Mary
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Dispatch
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« Reply #6 on: December 15, 2008, 10:53:04 PM »

:D HI adventurer06!

What the insurance company is doing to Oreo and myself is called subrogation.  I am sure there are others out there this is happening to as well.

So, Medicaid paid out over $50,000...hhhmmm VNS is supposed to cost only $25,000 for device & implant costs-that's what their lying advertisements say all over the internet.  Maybe we need to take a poll of who got the $25,000 VNS special of the week.  

Again, congratulations on winning your appeal!

B)
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VNS for TRD implant November, 2006.  Complete device removal including coils April, 2008.

"I reckon it's again my turn to win some or learn some..." Jason Mraz

ALL MY POSTINGS ON THE VNS MESSAGE BOARD ARE NON-TRANSFERABLE
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« Reply #7 on: December 16, 2008, 02:05:25 AM »

Congrats Mary.   :)  
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adventurer06
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« Reply #8 on: December 16, 2008, 04:45:01 AM »

Just wanted to give a big  :Thanx: to everyone who responded to my post. I guess time will tell if they will actually pay for a new generator when its time. And yes, Dispatch, I was shocked when I saw what the hospital bill was. You could get 2 new cars for that price. It sounds like Cyberonics is way over charging for this device, and the hospital came out pretty good too for only a 23 hr stay. I'm just grateful it is working for my depresson. I go back for another adjustment Thursday. When it was shut off I began to , at first just subtle changes but then I was beginning to feel a major episode coming on. I have been improving steadily with each adjustment now.
Mary
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gel61820
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« Reply #9 on: December 16, 2008, 09:21:32 AM »

Hi Mary,

I am so glad to hear that you won your appeal.  That is just fantastic news!

I went back and found that my VNS implantation was just under $70,000 while the explantation was approximately $24,000 (these amounts include hospital, surgeon, pre-op, etc).  In both instances I was outpatient but kept overnight for observation.  It does amaze me at the cost considering removing in some ways was more difficult (dealing with the scar tissue, and in my case bringing in another surgeon due to some complications).

I am really happy to hear that you are already seeing some improvement from the adjustments.  Please stay in touch and let us know how things progress.

Hugs,
Cindy
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VNS implanted July 2007 for Epilepsy.  Activated August 2007.  No success, so VNS was turned off in August 2008 and COMPLETELY removed (including coils) on Nov 25, 2008.
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« Reply #10 on: December 16, 2008, 09:51:16 AM »

Hi Mary,

Thanks for all the helpful info you put in your letter.  It may well be helpful to me too.

In this very backwards world...the insurance policy is written in such a way, that you cannot seek legal recourse until you go through several lengthy, ridiculous reviews and appeals within the Aetna system.  

If you aren't successful within their system (hm-m-m-m-m), you have to take it through your state insurance commission for an external review.  The state commission is supposed to be the "watch dog" to make sure there are no unfair practices by the insurance company.

Unfortunately, many state insurance commissions are as flawed as the insurance companies.  So....although ODI (Ohio Dept. of Ins.) sent my case for an external review - the review favored the insurance company.  This does not mean that ODI has to honor that...in fact the outside review was so ridiculously mixed up it was a total joke.  We should be going for a face to face meeting with ODI by the middle of January.

My husband (we are very recently separated) is a lawyer...and we have the law on our side, also out-right documentation from Aetna that they approved the surgery, and numerous documents that will allow us to take Aetna to court for unfair practices if ODI does not order them to cover all past and future expenses.

It takes such a long time because of the way the law allows insurance companies to drag out the process when there is a disagreement.  I am a pretty reasonable, peaceful person, but at this point, if we don't get things taken care of, I will be one of those people who will sue Aetna for $$$$$$$$$$$$$$$$$$$$$$$$$$ for unfair practices and for pain & suffering.

It doesn't take a genius to understand that a person with bipolar disorder who has been suicidal 24/7 for many years will be adversely affected by all this #%^&*!!!  In fact, the VNS along with my meds has me in the best condition I've been for over 15 years, but this fuss is taking its toll and if the battery runs out before the coverage problem is fixed....I will most certainly be back in hell.

I am so grateful for people like you who post their success stories.  It really does help to know each time someone gets justice in this crazy system.

 :yes2:  I'm hanging in there!  Oreo
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« Reply #11 on: January 10, 2009, 02:17:42 PM »

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Dear Mary,
CONGRATS to you, you should feel pretty proud of yourself.  I have a VNS too, have Aetna insurance.  I have not asked them if they would pay for a replacement battery or not.  Mine has been in over a year, and it has really helped me to improve my life.

I am 50 now.  It's great you have written confirmation that Medicaid will pay for your adjustments etc.  I too had to fight with Aetna for about 1-2years before they granted me the permission to get the VNS.  My setting is low; about .75H, and I cannot go above or below those settings.  I'm hoping my battery will last awhile at this low setting.  I had severe depression.

Again congrats!!!  Now you can rest awhile. :Yeah That:  :yes2:

Sincerely,
Bonnie
[/color][/size]
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« Reply #12 on: January 11, 2009, 08:35:57 AM »

Nice to hear from you Bonnie. Glad the VNS is working for you.
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adventurer06
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« Reply #13 on: January 13, 2009, 10:45:57 AM »

Bonnie,
Glad to hear you are getting good results from the VNS. I have had mine a little over 2 years ago and it has done wonders for my depression that I struggled over 18 years with.
It turns out the letter that I recieved, my lawyer recieved, and the billing lady in my dr's office recieved- only covered 1 unit ( which covers 1 visit for only 1 adjustment!!!) but they failed to mention that letter they sent all of us- we found out because they denied another adjustment and only paid the one. So now I have to go through the process all over again possibly one by one for each visit. They have only so far paid 1 of my 6 adjustments. Every one thinks it bogus, and I am plain sick of Medicaid. I should not have to appeal for payment of each adjustment I have, especially since they admitted in a letter that it was their own error. And I think, since they paid the $50,000 for me to be implanted with no problem, they should cover follow up and not waste their money/investment.  I just won the last appeal Dec 20th, so I'm clueless why I even have to do the appeals again. I guess they are just wanting to be difficult hoping I'll get tired of fighting them. I'm sure you know what I'm talking about since you had to deal with your insurance for 2 years.
The good news is that I just went for my highest adjustment last week, up to 1.50. So now I only have to go every 6-12 mos (depending on if my insurance will cover or not) for them to check the battery and leads. So I am still happy to be implanted- and so far- no more problems with the device.
I hope you continue to do well with your VNS. Its nice to hear from lucky ones like us that it works for. Hopefully we will both be able to keep ours when our batteries die.
Mary

 
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