DEALING WITH INSURANCE FOR BAHA COVERAGE

[terisandler]

My health insurance denied the BAHA.  One of the several reasons given is it is not a standard medical procedure as accepted in the insurance industry.  I know that it is covered by many insurance carriers and Medicare.  I am appealing this decision and feel it would be helpful to list names of insurance carriers that do cover it.  Can any of you name carriers that cover BAHA.  Thank you.

[CHD63]

I saw your post on Facebook, but decided to reply here for additional information to others not on Facebook.

My Oticon Medical Ponto Pro was completely covered (both the abutment implant and the processor itself) through my Humana Medicare.  In my case, my Humana supplement insurance and medicare are all rolled into one.  It was approved on the first submission by House Ear Clinic.  I truly feel it is a matter of the right codes and right diagnoses/arguments presented on the initial submission.

That being said, some insurance companies will do everything they can to keep from paying a claim.  Unfortunately it is up to the patient to appeal, appeal, appeal to the highest level before they knuckle under and agree to pay.  The baha devices are prosthetics necessary to us the same as a prosthetic limb is necessary to patients who lose an arm or a leg.  As someone on Facebook said, this is not an age-related condition.

If I were you, I would keep appealing this decision, making certain it is coded correctly by your doctor and then documenting all of the reasons you can think of as to why this is a better option for you than a bi-cros/transear device.  I think your insurance company may be playing games with you and hope you give up fighting it.

Good luck and let us know how it goes.

Clarice

[terisandler]

Humana is sticking to their assertion that it is a hearing aid.  I am appealing to my former employer's medical director and plan administrator (I am covered by a self funded plan that is administered by Humana.  They  just opened their review so I probably won't know for a few weeks.

The Oticon insurance department looked up their code for the Ponto vs my insurance policy and told me it is excluded.  My audiologist and otologist's office manager both told me that insurance carriers have begun to consider them hearing aids.  Humana's claims department told me the only coverage they approve is for children's cochlear implants. 

It seems like they have all the loopholes covered.  I am going to see if Oticon has a legal department and also plan to call the Cochlear legal department.  I cannot bear the expense of a lawyer's fees (still paying installments on my out of pocket responsibility for CK) - and don't know how to find one to take this on maybe as a class action suit pro bono.

Thanks for your encouragement, Clarice.

Teri

[james e]

My insurance was with Aetna and they approved it with a phone call from my doctor.

[Brewers7]

My insurance is administered by Aetna.  They view it as a prosthetic device and not merely a hearing aid.

[terisandler]

Thanks, all. 

[terisandler]

My neurotologist's office manager informed me that the Humana liaison for my employer called to investigate the cost for the Ponto.   She thinks this is a good sign.  Holding out positive thoughts that she is right.  Also have my fingers and toes crossed....

[CHD63]

I'd take that as a good sign, as well.  Crossing my fingers and toes for you .....

Throwing in some good thoughts and prayers too .....

Clarice

[terisandler]

Thanks.  Every set of crossed fingers & toes helps!

[terisandler]

Received the final answer about my insurance appeal - coverage for the Ponto Pro Power BAHA is denied.  The only recourse left is an ERISA appeal (whatever that is) but USAA pretty much quashed that by citing language that cochlear implants are only considered in the case of total deafness ....

[jaylogs]

Ugh Teri!! So sorry you are having to go through all this....crap! Have you gotten Oticon involved? I know that Cochlear has people that can fight for you.  If Oticon can't or won't maybe decide to go with the Cochlear flavor and have them fight for you...it might be worth it even though you aren't getting quite what you want...good luck! Hang in there!
Jay

[terisandler]

Jay, I spoke to the insurance division at Cochlear and they said it is up to my former employer (USAA) to decide wether or not to offer coverage and the answer is a resounding "NO"!  I left a message for somebody at Oticon and never received a call back.  Looks like it's going to be the Phonak BiCROS.

[kixit]

My insurance is with Anthem. They denied my request for the Baha. With help from Cochlear, I appealed and won the first go around. I filled out all of Cochlears paperwork and wrote a personal letter to the insurance company about quality of life, SAFETY (such as walking through a crowded parking lot and not being able to HEAR traffic because of surrounding noises) and so. I faxed it all to Cochlear and they did the rest.

I wish you great luck and don't give up!!

[alabamajane]

Teri ,
Am I missing something here,, you say USAA denied it saying "language says cochlear implants are only considered in cases of total deafness ",, but a BAHA and cochlear implant are two totally different hearing solutions,,, CIs ARE for total deafness but a BAHA is not,, you can't qualify for both,, it's either or,,, maybe I missed something,,,

I would keep trying too if the BAHA is what you are wanting,, good luck! Jane

Received the final answer about my insurance appeal - coverage for the Ponto Pro Power BAHA is denied.  The only recourse left is an ERISA appeal (whatever that is) but USAA pretty much quashed that by citing language that cochlear implants are only considered in the case of total deafness ....

[terisandler]

Jane, I probably omitted the wording that the only covered device is a CI and only in the case of total deafness.  I am currently trying out a Phonak Bolero BTE unit with an ear mold in my AN ear.  I have some limited hearing but poor word discrimination in that ear.  Just picked it up on Monday but it seems to be working out.  The true test will be a noisy restaurant with poor acoustics...