Battling the Health Insurance Appeal

Insurance companies are like a business. They are out to make money and with that being said, they are looking out for their assets. If insurance companies approved every claim that came through, they would burn through their resources very quickly. This is why insurance companies work the way that they do. By providing a set list of covered benefits, they control the amount of claims that come through and can control the amount of money spent on those benefits.

With that being said, it does not mean that an individual cannot receive coverage for a needed device or treatment. It is just that the insurance company wants to know that this device or treatment is really needed AND is going to be helpful.

For example, the Bioness or WalkAide device used for the treatment of foot drop. For many, if they were to contact their insurance provider and inquire as to whether the device was covered under their plan, they would be told ‘no’. This can be very discouraging and can spark some anger in those who struggle with foot drop. But if we look at ‘why’ the insurance companies deny this device initially, it can make sense.

The Bioness or WalkAide devices have not been FDA approved for the treatment of foot drop in MS, meaning that there have not been clinical trials to prove that this device is clinically effective for those with MS. Unfortunately, without the FDA approval insurance companies may have the upper-hand. They are trying to protect their assets and don’t want to provide an expensive device and have that device not be effective.

So what can you do?

Insurance companies require what is called a ‘burden of proof’, meaning that you must provide enough proof and evidence to the insurance company that the device or treatment is helpful to you in your situation. Using the example of the Bioness or WalkAide, by locating a physical therapist that works with this device, or one that can assist with receiving a trial, you can help to build your case against the insurance company. Physical therapy reports of the devices effectiveness can be used in the appeal process to provide the burden of proof needed for the case.

While insurance appeals can be a challenge and possibly delay treatment or assistance from a medical device; decisions can be overturned and won. By understanding the system and how and why an insurance company requires this information, you give yourself the advantage in the appeals process.

 Have you won an insurance appeal? What steps did you take to ensure your success?

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Comments

  • Jessica Jay says:

    Currently denied by BC/BS for Bioness for 8 yo daughter with Cerebral Palsy left side affected. Bioness picks her foot up so she walks straight and doesn’t trip or drag toe. I’m at a loss as why they automatically deny a child. This could make her life nearly normal!!!

    • Angel says:

      Thank you for reaching out, Jessica. It can be very challenging and frustrating trying to work with the insurance for coverage when they place barriers to care for services, especially if something has been effective like the Bioness system has been for your daughter. I would encourage trying to work with her doctor and medical team to appeal the insurance decision, and for them to help explain how effective and useful the device has been for her. Hopefully they can help get the decision overturned so your daughter can continue receiving benefits from the device. Please feel free to reach out to the MSAA Helpline for additional information or resources, phone (800) 532-7667, ext. 154. Take care and best of luck to you.

  • William Henehan says:

    Being denied for ‘Walkaide’ for foot drop caused by Multiple Sclerioos.
    Any help suggestions?

    • Angel says:

      Hi William, thank you for reaching out with your inquiries. Because the Walkaide device is not specifically FDA approved for MS at this time, it can be very challenging to have insurance plans cover the system, though it has been proven effective for those who’ve tested the device and has helped manage the MS foot drop symptoms. My suggestion would be to try and work with your doctor and medical team to have them try to appeal the decision with your insurance to see if the outcome changes; having them explain how effective the device has been for you and its benefits will hopefully add to its necessity. You can also try to work with the manufacturer of the Walkaide system directly for assistance in finding coverage or funding options they may offer as well. Please feel free to reach out to the MSAA Helpline for additional information or resources, phone (800) 532-7667, ext. 154. Take care and best of luck to you.

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