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INSURANCE COVERAGE FOR NEEDLE APONEUROTOMY
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08/12/2010 13:25
dave t

not registered

08/12/2010 13:25
dave t

not registered

Re: INSURANCE COVERAGE FOR NEEDLE APONEUROTOMY

I had full BC/BS coverage in a PPO plan two years ago. I initially got denied for xiaflex this spring by the same plan (same reasons for denial as you). See my appeal process on this forum under "My xiaflex experience". good luck.

10/27/2010 14:52
Architect 
10/27/2010 14:52
Architect 
Re: INSURANCE COVERAGE FOR NEEDLE APONEUROTOMY

UPDATE 2010-10-27 11:16:00

After 2nd appeal to insurance company... they DENIED my claim.


FROM DENIAL LETTER...

The Coventry Health Care of Florida, Inc. internal Review Panel "The Panel" conducted your second level hearing on October 13t, 2010. After review of your (second) appeal, the Panel has decided to uphold the original denial since efficacy has not been established, Needle Aponevrotomy in the treatment of Dupuytrens Contracture continues to be considered investigational / experimental. This decision was based on the following:

In accordance with your Certificate of Coverage, under Section 5, Exclusions and Limitations page 32, it states: "Experimental Procedures: Procedures determined by the U.S. Food and Drug Administration (FDA), The American Medical Association (AMA) or the Health Plan's Medical Director to be experimental or investigational."



My remaining option.. I can appeal to the State of Florida Agency for Health Care Administration (AHCA) for review of my grievance by the Subscriber Assistance Program (SAP). If I am a member of an employer plan then i would have the right to bring civil suit under Scetion 502(a) E.R.I.S.A.

Bottom line... DENIED!!!

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