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I need help with a medical procedure insurance denial that is necessary? |
I had an MRI a couple weeks ago, which showed a syrinx in my spinal cord (also known as syringomyelia). The MRI was for brain/neck only and was done because I was having headaches. I need to have an MRI on my entire spine to rule out more syrinx formation. Syringomyelia is very serious and can cause paralysis and/or death if not treated. My dr. has attempted twice to get approval for another MRI. She got the neck and brain approved to be done again with contrast to rule out other pathology but twice they have denied doing the whole spine. Is there anything I can do to fight this and get the further MRI testing since its medically necessary? Also, it takes a highly trained specialist to deal with syringomyelia because it is so rare. None of these specialists are in my state (only drs. in my state accept my insurance). Is there a way to get them to pay for me to go to another specialist? I had a conversation w/my ins. co. this morning and they say "no" since there ARE neurologists here. When you don鈥檛 have money to get the care you need, here are some free resources for you, read through them, and pick up the phone, and get your needed help. http://www.nlm.nih.gov/medlineplus/finan... http://ask.hrsa.gov/pc/ http://www.omhrc.gov/templates/browse.as... http://www.hrsa.gov/help/default.htm... http://www.thefrugallife.com/medicalalte... http://www.google.com/search?q=free+low+... Free and low cost prescription medication: http://www.xubex.com/ https://www.pparx.org/intro.php... http://www.nami.org/template.cfm?section... http://www.themedicineprogram.com/links.... http://www.cancer.gov/cancertopics/facts... Financial Assistance and Other Resources for People With Cancer:Cancer imposes heavy economic burdens on both patients and their families. For many people, a portion of medical expenses is paid by their health insurance plan. For individuals who do not have health insurance or who need financial assistance to cover health care costs, resources are available, including Government-sponsored programs and services supported by nonprofit organizations. Cancer patients and their families should discuss any concerns they may have about health care costs with their physician, medical social worker, or the business office of their hospital or clinic. This is about FREE hospitalization, if you need it and they WILL help you! http://www.hrsa.gov/hillburton/default.h... Hill Burton Hotline 1-800-638-0742 (1-800-492-0359 in Maryland) In 1946, Congress passed a law that gave hospitals, nursing homes and other health facilities grants and loans for construction and modernization. In return, they agreed to provide a reasonable volume of services to persons unable to pay and to make their services available to all persons residing in the facility鈥檚 area. The program stopped providing funds in 1997, but about 300 health care facilities nationwide are still obligated to provide free or reduced-cost care. http://www.hrsa.gov/help/default.htm... Medicaid is for people under 65, medicare is for the seniors. How to apply for Medicaid or medicare http://www.cms.hhs.gov/medicaideligibili... http://www.aarp.org/money/lowincomehelp/... For information about Social Security, Medicare, and disability benefits, call the Social Security Administration at 800-772-1213. http://www.ssa.gov/ For information about Medicaid, contact your local social service or welfare office. You can also find information about Medicare and Medicaid at www.CMS.gov How To Pay for Mental Health Services http://mentalhealth.samhsa.gov/publicati... http://depression.about.com/cs/findadoc/... Additional Public Benefits for Families Raising Children: http://www.nlm.nih.gov/medlineplus/finan... DENTAL HELP: Free or low cost dental care United States http://www.nidcr.nih.gov/nr/rdonlyres/53... http://www.raconline.org/info_guides/den... FREE AND LOW COST DENTAL HELP FOR DENTURES , BROKEN TEETH , PAIN , ETC. http://dental-assistance.app-sl-1.aidpag... Need eyeglasses or eye care? http://www.nei.nih.gov/health/financiala... http://www.uniteforsight.org/freeclinics... Free Mammogram: http://www.cdc.gov/cancer/nbccedp/... How to Get a Free or Low Cost Pap Smear, The National Breast and Cervical Cancer Early Detection Program provides free or low cost Pap smears to eligible women across the country. Through this program, uninsured and impoverished women can receive Pap smears at local clinics and doctor's offices. Here鈥檚 a list for every state: http://cancer.about.com/od/screeningandd... Where can I go to get free or reduced-cost prenatal care? You can call this number if you need free birth control help, too! Women in every state can get help to pay for medical care during their pregnancies. This prenatal care can help you have a healthy baby. Every state in the United States has a program to help. Programs give medical care, information, advice and other services important for a healthy pregnancy. To find out about the program in your state: 路Call 1-800-311-BABY (1-800-311-2229) This toll-free telephone number will connect you to the Health Department in your area code 路For information in Spanish, call 1-800-504-7081 路Call or contact your local Health Department. Ask for your medical records too. Write an appeal letter. Complaint form to the Insurance/Medical with the State appeal. Look in your government yellow page and your book you receive, call them they are suppose to give you this information. you should call your ins. co & ask who you need to see since it sounds like the physician you are seeing is out of network. the ins co should be able to provide a list of which neurologists / neurosurgeons within your network. dont be fooled by thinking you are going to the "best" specialist, etc. i work for an ins co & many consumers are grossly misinformed about their own dr. - Many do not even check the drs history, such as the medical board for disciplanary actions, education, publications and board certifications. it is found that if another person brags on that dr as "the best" then it is taken as face value. some of the best physicians you will find are at teaching hospitals. it sounds as if your 2nd MRI may be able to be covered provided you go to a specialist in your network. The services you receive out of network may be covered if you are on a PPO, it just may apply to an out of network deductible (which you are liable for) an HMO though you will probably be fully responsible for if you go out of network. Also keep in mind, physicians that CHOOSE not to be in a network may not be eligible due to disciplanary actions taken against them. PPO and HMOs will rarely allow a physicians or hospital to remain in their network that has actions against him. good luck. ins industry 17+yrs A lot of the care you can get that is covered by your plan is determined by the plan that was purchased. You must be on an HMO plan. If it was a PPO plan, you can get care anywhere you want. It is just that the benefits are reduced (deductible is 2 or 3 times higher, and percentage paid after deductible is 20 to 30% lower) when you use a physician that is out of network. Ask your insurance company to get you a case manager assigned. This will be the person you will go through for all insurance questions and needs. Study your policy and make sure you understand the care you are entitled to. You may even want to have an attorney check it out for you. If it appears that you do not have coverage for the physicians and facilities you want, it will do no good to sue. You are already getting exactly what was promised in writing. But, you may be able to get some public assistance or something. Good luck, and God bless you. insurance agent 23+ years If you have an insurance agent, get them involved right away. You're paying for their services. They know the lingo and often have contacts within the carrier to find the person who can say "yes." (Anyone can find the people who can say "no." The fact your doctor is supporting you is a good thing. Each insurance company has a Chief Medical Officer. I suggest you check out their web site and send that individual a certified letter. Include the fact that your doctor deems the procedure necessary. Send a copy of the letter to the president of your health plan. Most carriers have a staff of folks who deal with letters to the president or CEO of a company. Sorry you're having such problems. Hang in there. |
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