BAHA Denial, have appealed multiple times with Cochlear OMS help

[sable31573]

I am looking for anyone who can help me. I have been denied multiple times for the BAHA. I had a 4.5cm tumor that left me with single sided deafness. I had 2 surgeries to remove the tumor, I have had 2 gold weights put in my eyelid, a cornea transplant, the seven to twelve nerve jump graph. My insurance is a self funded plan. This whole BAHA process has been a nightmare. First few times insurance stated not medically necessary. Now they are no longer saying not medically necessary but that they do not like the billing codes. I have checked and the codes are correct. I am so tired of the back and forth that has been going on. I have even been to Human Resource employee for help. I thought we were moving in the right direction and now I get they are back to the codes. They want Cochlear to use a different code and Cochlear says this is the correct code. My doctor keeps saying I will win this but it has gone on now for over 10 months. Anyone else had this problem. I really need this as I am having lots of difficulty in my job.

[leapyrtwins]

I'm sorry to hear about all the trouble you're having.  I didn't have this much trouble getting my insurance company to approve my BAHA, but I know others who have been through this.  If it's any consolation, I can tell you that if you keep pursuing coverage, chances are good that you will "win".  Most insurance companies think that people will give up after the first denial - after all, it saves them money - but if you persist you'll get covered.  Don't take no for an answer.   

Believe it or not, you may have to educate your insurance company about what a BAHA is and why you need one.  Most insurance company personnel and doctors have no idea what a BAHA is; even my ENT was clueless when I informed him I had gotten the implant and amazed when I told him how it worked.  You should ask for a peer to peer review of your request.  This will insure that a doctor who does BAHA implants will actually review your request, rather than a doctor who doesn't.  A peer to peer review is something you are entitled to.

Also, although it sounds like you already know this, it's important to make sure the BAHA is coded correctly - it's not a hearing aid, it's classified as a prosthetic or an implant.  It also doesn't hurt to stress that a BAHA will give you a better quality of life and also alleviate (potential) depression on your part due to lack of hearing.

Getting a BAHA implant after my AN surgery left me SSD was the best thing I've ever done.  I was miserable and so were my kids who hated to hear me keep asking "what??"   

Hang in there and don't give up; it's worth it.

Best,

Jan

Forgot to mention that you should see if your insurance covers Cochlear Implants (CI's).  CIs are for those who are bilaterally deaf.  If your insurance company covers CIs and doesn't cover BAHAs you can claim that they are discriminating against you (because they are) since they are covering those who are bilaterally, but not unilaterally deaf. 

[sable31573]

I have no intentions on giving up the fight, My next step is an attorney. I am not able to do a peer to peer review because they are not saying its not medically necessary. They are not fighting that, if they were then I could have the peer to peer review. They keep coming back with it is a hearing aid and you do not have coverage for a hearing aid. I have, along with Cochlear, submitted many documents proving it is not a hearing aid. They just won't look at anything. I went to Human Resource Department because that is what they recommended at Cochlear. I thought we were heading in the right direction, but it turns out employer on the self funded plan keeps hiding behind the so called insurance company and the insurance company keeps blaming the employer. I have pointed out my coverage for Prosthetic multiple times to both the employer and the insurance company.  I just don't know how to get this craziness to stop and someone to look at what the facts really are. So so frustrating! If anyone knows how to handle this, please respond. If I need to get a lawyer I will do that. Our so called insurance is with Anthem Blue Cross Blue Shield, which on a self funded plan is just the 3rd party administrator.

[leapyrtwins]

From my experience with self-funded plans, the employer can ask the insurance company to cover just about anything they want covered.  The employer is the one who makes the "rules"; the insurance company just follows them and processes the claims.  Have you filed a complaint with your state insurance department?

You might have to sue your employer. 

Another route that a few people here in Illinois have taken (successfully) is to make your case through a "media campaign".  Take the issue to your local newspaper or TV station - especially if they have reporters who deal with public interest stories or consumers being "ripped off".  Sometimes all it takes is a little bad publicity to get an employer (or insurance company) to do the right thing.

You could also start a petition through www.change.org 

Good luck.

[sable31573]

I am happy to report I received an email today that I have finally been approved for the baha, after 10 months of appeals. My email says my letter will be sent out ASAP. 

[Necromancer]

Congratulations on finally getting your appoval. I had to jump through hoops to get mine approved.