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?