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INSURANCE COVERAGE FOR NEEDLE APONEUROTOMY
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06/07/2008 16:35
JJACOBWILL

not registered

06/07/2008 16:35
JJACOBWILL

not registered

INSURANCE COVERAGE FOR NEEDLE APONEUROTOMY

Today, June 7, 2008, I received a denial by my insurance provider, Health Partners of Minnesota (an HMO), of pre-authorization for N.A. for my Dupuytren's Contracture in both hands. Their reason for denial is "...it has been determined to be experimental/investigational...". My primary care MD submitted to my HNO for treatment by Dr. Eaton at the Hand Center in Jupiter FL.

I intend to appeal and my questions are:
1.) are any users of this forum aware of any others who have been successful in obtaining coverage from their providers, e.g., Blue Cross-Blue Shield, Prudential, etc.;

2.) any suggestions for the appeal process. I've researched this site and found a 5/11/2006 post from Steve, in which he includes his actual letter referencing CPT code 20640 and Meicare coverage.

3.) Shouldn't the Medicare approval be sufficient precedence?

Thanks to any who can assist me in this appeal.

06/07/2008 22:20
moondanc 
06/07/2008 22:20
moondanc 
Re: INSURANCE COVERAGE FOR NEEDLE APONEUROTOMY

I received coverage several years ago from Healthnet PPO although only at 50% out-of-network rate and recently through a Blue Shield Medicare policy. As I recall, Dr. Eaton's website has a bunch of information on what to say and how to say it in appealing one's decision. Perhaps you might email or call them for suggestions.

That said, though, I'm not sure how this works with an HMO other than asking them to point to someone in their network who does the procedure. I encourage you to keep appealing, though, as insurance companies count on people not doing that and routinely deny coverage. I'd continue to emphasis the Medicare coverage and make them explain how they can call it experimental.

06/07/2008 22:26
moondanc 
06/07/2008 22:26
moondanc 
Re: INSURANCE COVERAGE FOR NEEDLE APONEUROTOMY

From another post on this site, here's a link to the Mayo Clinic website which lists NA as a treatment. Ask your insurance company to refute that!

http://www.mayoclinic.com/health/dupuytr...0732/DSECTION=7

06/08/2008 04:09
diane s

not registered

06/08/2008 04:09
diane s

not registered

Re: INSURANCE COVERAGE FOR NEEDLE APONEUROTOMY

two years ago blue cross california covered my na. i had a higher decuctable apply because the provider was not contracted with blue cross, but the treatment was covered - no questions.

07/20/2008 14:52
Sandra

not registered

07/20/2008 14:52
Sandra

not registered

Re: INSURANCE COVERAGE FOR NEEDLE APONEUROTOMY

Two weeks ago my HMO, UCSD Medical Group, gave out of network approval for NA. My hand surgeon and I had been communicating since January, 08 about NA and he said he would submit a referral, but my insurer, Pacific Care, said I would have to see my Primary Care doctor (who knew nothing about Dupuytrens). I made the mistake of mentioning to her a particular Dr. at UCLA referred by my hand surgeon at UCSD. There is no one in San Diego who performs NA through my medical group and so they denied it but gave a conditional approval to have hand surgery with my current hand surgeion! I then had to go back to my hand surgeon, who then submitted a request for authorization without mentioning a particular Dr.
and it was approved. I recommend not mentioning a particular Dr., just the procedure which is much less costly for the insurer and less invasive for the patient. Now my medical group said I would have to ask my hand surgeon to refer me to a particular Dr.! Can you believe it? He initially referred me to Dr. Eaton, but when I asked if there was someone closer, he found Dr Benheim at UCLA with whom I have been communicating since February. I had a rebuttal ready with educational information about Dupuytren's to submit to my insurer in the event that they refused my hand surgeon's referral. Good luck!

08/09/2010 15:41
Architect 
08/09/2010 15:41
Architect 
Re: INSURANCE COVERAGE FOR NEEDLE APONEUROTOMY

2010-08-09

Hello fellow Dupuytrens Forum members..

I am located near Dr Charles Eaton in South Florida and received a rejection letter from my HMO (Coventry/Vista) regarding the Needle Aponeurotomy (NA) procedure Dr. Eaton performs as being "experimental / investigational". I am in the process of filing a "Grievance/Appeal" per the HMO's standard procedure. [Don't want to be accused of not following proper protocol(s).]

I have been doing a lot of research on the subject and to date Dr. Eaton's office indicates that since 2003 they have performed over 8000 NA procedures. Another local surgeon, Dr. Terrance Barry's website indicates that his office has performed over 1200 procedures. On other websites there are many physicians/surgeons who perform NA. I am wondering how many procedures need to be performed before not being referred to as "experimental / investigational"? Clearly there must be more than 10,000 performed and I am sure is well over that amount. Who draws the line on what is experimental? Anyone have any ideas on that?

Dr. Eatons office tells me that the NA procedure is covered by Medicare. I know that Dr Eaton is not "IN NETWORK" but I am not looking for the full coverage but the typical 50% "out of network" coverage. After all, the HMO cashes my premium checks like clockwork every month. They have no problem taking my money each month. The NA procedure has so many positives and is obviously less expensive all around and with a faster and more beneficial outcome for all parties concerned. So why is it that after at least 7 years and countless procedures performed does the insurance company so easily reject legitimate claims?

I realize that it has been sometime since the last posts in this thread but am hoping that you are reading this and will provide an update as to your progress and whether further NA procedures were or are necessary?

Any information that can help to substantiate my appeal to the HMO is gratefully appreciated.

Thanks again,

Keith
Architect
South Florida

08/09/2010 15:53
jimh 
08/09/2010 15:53
jimh 
Re: INSURANCE COVERAGE FOR NEEDLE APONEUROTOMY

A year ago I had an NA performed at Mayo (in Rochester MN) and my insurer (Medica) didn't blink, they paid their portion for an out-of-network service.

This procedure is now roughly 30 years old and has a solid track record. If an insurer is still calling it experimental, they're just misinformed. My fear though is that they're getting this misinformation from hand surgeons who lack knowledge of this technique.

Edited 08/09/10 18:56

08/09/2010 19:35
Architect 
08/09/2010 19:35
Architect 
Re: INSURANCE COVERAGE FOR NEEDLE APONEUROTOMY

THANKS JimH for the input..
30 years is a long time to experiment.

Dr. Eaton is right in my neighborhood (South Florida) , and it is reported that he was the first in the USA to use this procedure... I just cant see how the HMO can so easily deny using NA.

08/10/2010 00:54
SteveAbrams

not registered

08/10/2010 00:54
SteveAbrams

not registered

Re: INSURANCE COVERAGE FOR NEEDLE APONEUROTOMY

Check out my successful appeal of an HMO rejection of payment to Dr. Eaton:

http://www.dupuytren-online.info/Forum_E...77&page=1#6

Steve Abrams

08/10/2010 02:24
Architect 
08/10/2010 02:24
Architect 
Re: INSURANCE COVERAGE FOR NEEDLE APONEUROTOMY

Thank you for the info re your appeal letter.

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