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#21
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Breastfeeding not medically necessary
Pologirl wrote: Well, that sucks big time. How about a different approach? Such as: medically necessary to rescue normal function of the milk ducts. Breastfeeding evidently is not medically necessary for your baby, because she is thriving on formula. But normally functioning milk ducts may be medically necessary for you: prevention of mastitis and other direct effects of the blockage; indirect effects such as lower risk of breast cancer, etc. Those reasons might add up to a stronger case for medical necessity. I agree with you, this seems to be a less controversial approach... I'm going to try that! |
#22
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Breastfeeding not medically necessary
There is another possibility: that the claim was denied simply because the particular code used by the surgeon's billing specialist is one not recognized among the set of codes that are pre-approved as indicating "medical necessity" within the surgeon's specialty. To deal with this angle, you have two approaches. 1. Discuss with the billing person the code(s) actually applied to your claim, and what other codes might apply. 2. Request the insurance company to review your case. But before you do anything, it might help to "get your head around" the whole concept of "medical necessity". Eg: http://www.aph.gov.au/Library/pubs/R...-01/01RP23.htm Wanting to breastfeed is why you care about normal function, but the ability to breastfeed in itself is not a compelling medical reason. Restoring normal function usually *is* a compelling medical reason. |
#23
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Breastfeeding not medically necessary
Lady Penelope Creighton-Ward wrote: Pologirl wrote: There is another possibility: that the claim was denied simply because the particular code used by the surgeon's billing specialist is one not recognized among the set of codes that are pre-approved as indicating "medical necessity" within the surgeon's specialty. To deal with this angle, you have two approaches. 1. Discuss with the billing person the code(s) actually applied to your claim, and what other codes might apply. 2. Request the insurance company to review your case. But before you do anything, it might help to "get your head around" the whole concept of "medical necessity". Eg: http://www.aph.gov.au/Library/pubs/R...-01/01RP23.htm Wanting to breastfeed is why you care about normal function, but the ability to breastfeed in itself is not a compelling medical reason. Restoring normal function usually *is* a compelling medical reason. This is extremely helpful information, thank you so much! Some googling that might be helpful: keywords: Massachusetts, HMO, "medically necessary," denial This will bring up, at the least, the contacts (pre-legal) for pursing an appeal. Additionally, other cases brought up will indicate law firms that have been involved. (Including a pamphlet from the AG's office) Agh. This is so tremendously frustrating. Please keep us posted. Caledonia |
#24
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Breastfeeding not medically necessary
Beth Kevles wrote:
Hi -- Escalate! If the insurance company fails to give satisfaction, your next step is your state's overseer of medical insurance companies. If THAT fails then I'd start writing to newspapers, etc, but hopefully this will succeed at the state level. Be sure to include, in your missive to the state commissioner (or whatever) information about health benefits to mother and child. On top of that, I'd find out if your state has a medical society, and if so try contacting their "government affairs" division, if they have one (which they probably would). They might lobby your state's legislators to change the laws so that insurance companies would not be allowed to second-guess your physician's judgment on the medical necessity of doing a surgery that allows you to bf. -- Belphoebe |
#25
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Breastfeeding not medically necessary
Belphoebe wrote:
Beth Kevles wrote: Hi -- Escalate! If the insurance company fails to give satisfaction, your next step is your state's overseer of medical insurance companies. If THAT fails then I'd start writing to newspapers, etc, but hopefully this will succeed at the state level. Be sure to include, in your missive to the state commissioner (or whatever) information about health benefits to mother and child. On top of that, I'd find out if your state has a medical society, and if so try contacting their "government affairs" division, if they have one (which they probably would). They might lobby your state's legislators to change the laws so that insurance companies would not be allowed to second-guess your physician's judgment on the medical necessity of doing a surgery that allows you to bf. Following up on my own post, I noticed Caledonia mentioned Boston, MA in her reply to you. Here's contact information for the Massachusetts Medical Society: Massachusetts Medical Society 860 Winter Street Waltham MA 02451 (800) 322-2303 or (781) 893-4610 Their web address: http://www.massmed.org//AM/Template.cfm?Section=Home -- Belphoebe |
#26
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Breastfeeding not medically necessary
Belphoebe wrote: Belphoebe wrote: Beth Kevles wrote: Hi -- Escalate! If the insurance company fails to give satisfaction, your next step is your state's overseer of medical insurance companies. If THAT fails then I'd start writing to newspapers, etc, but hopefully this will succeed at the state level. Be sure to include, in your missive to the state commissioner (or whatever) information about health benefits to mother and child. On top of that, I'd find out if your state has a medical society, and if so try contacting their "government affairs" division, if they have one (which they probably would). They might lobby your state's legislators to change the laws so that insurance companies would not be allowed to second-guess your physician's judgment on the medical necessity of doing a surgery that allows you to bf. Following up on my own post, I noticed Caledonia mentioned Boston, MA in her reply to you. Here's contact information for the Massachusetts Medical Society: Massachusetts Medical Society 860 Winter Street Waltham MA 02451 (800) 322-2303 or (781) 893-4610 Their web address: http://www.massmed.org//AM/Template.cfm?Section=Home -- Belphoebe Thank you so much, Belphoebe. The current status is that the breast specialist's nurse has spoken with the peer reviewer from the insurance company, and I am awaiting their new decision. The nurse said the doctor would be happy to speak with them if necessary, but for now this was all that was needed. I should be hearing back from CIGNA within 15 business days. |
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