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Thread: Suggestions for appealing suspension boot denial

  1. #1
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    Suggestions for appealing suspension boot denial

    Okay, so we have had suspension boots for 2+ years which were prescribed and given (and paid for by same insurance) while Danny was in the hospital and had heel pressure sores.

    Fast forward to November 2014. One of the plastic boots cracked and broke, rendering it useless. Naturally he now has a pressure sore on that heel. We immediately asked the doctor for a prescription for replacement boots which she gave him. The insurance denied covering these boots as "medically unnecessary." So - now he has to go to Wound Care every week to get these wounds healed. At first we thought the wound care doctor and personnel were going to appeal this denial, but all they said was, "oh well, they denied it."

    Seriously?

    Now I have been blessed enough to have medical insurance coverage that also covers my spouse. Coincidentally it is the same UPMC coverage - BUT - Danny's is a Medicare Supplement, mine is not. I asked MY concierge about getting these boots covered under MY policy and her response was, "If it was denied by his primary, it will be denied by the secondary also."

    I can-NOT believe that there is nothing I/we can do to get these boots covered! For goodness sake, it's not like he is asking to get a boob job - the man just wants to not have heel wounds that necessitate him going to wound care center every week!

    Anyone have any suggestions other than perseverance and tenacity to get these darn things covered?

  2. #2
    The first set of boots were likely approved as medically necessary because they were viewed by insurance as decubitus care accessories.

    Is it possible that medical documentation for your second set of boots gave insurance reviewers the impression that they were ordered for preventive purposes?

    If so, you'll need to go through the insurance appeals process with new medical documentation of a current decubitus needing pressure relief care.

  3. #3
    Senior Member NW-Will's Avatar
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    Just throwing ideas out there... is it possible to get copies of the original paperwork, so you can see how it was written up when they covered the boots, may give some clues how to write up the request to get them covered.

  4. #4
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    Thanks for the info 2drwofans and NW-Will - I am having my husband get the exact information from the supplier who informed him it was denied today. I just needed a little "help" with the process. Usually I can "convince" insurance companies of medical necessity - this is just the latest in a life-long "battle" with authority /sigh.

  5. #5
    Senior Member lynnifer's Avatar
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    I can always rely on eBay for cheap, used medical equipment.
    Roses are red. Tacos are enjoyable. Don't blame immigrants, because you're unemployable.

    T-11 Flaccid Paraplegic due to TM July 1985 @ age 12

  6. #6
    Quote Originally Posted by lynnifer View Post
    I can always rely on eBay for cheap, used medical equipment.
    They also sometimes have brand new equipment at very good prices as well.
    T6 Incomplete due to a Spinal cord infarction July 2009

  7. #7
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    I am not 100% sure,, but Medicare does not always cover something just because you have a doctor prescription. You end up needing evaluation from the Medicare identified" type of person. For example, they will not cover a wheelchair just because you have doctor prescription. You need a wheelchair evaluation for therapist who does that stuff. It is ridiculous, but this may be what is happening. Many times, place you are trying to purchase from either does not know about evaluation or simply are too lazy to go through that process.

  8. #8
    I was never able to get Medicare to pay for heel boots for my mother, even though she was at high risk for skin breakdown. Many insurances follow Medicare's list of approved medical devices/products. They may pay if it is used for TREATMENT, but not prevention.

    It sounds like the boots you were using were the hard plastic boots, which actually are very expensive, and can cause more problems than then prevent anyway. Look at a soft heel elevating boot, which are much cheaper. Some names are Sage Prevalon, Heelift, Posey Heel-Guard, Posey Pro-heelx, and Medline Heal-Medx.

    You can certainly file an appeal, but you will probably have to pay for these out of pocket in the long run. Try eBay (as above).

    (KLD)
    Last edited by SCI-Nurse; 01-21-2015 at 01:48 PM.

  9. #9
    There's one of these Goodwill Medical stores near me which is fantastic: http://www.goodwillhomemedical.org

  10. #10
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    We have the HeelLift boots and have actually been using these as a replacement for the one plastic one that broke. He IS healing and will probably be done with wound care in a couple of weeks. I had him get the original paperwork from the supplier and the Rx clearly states "Pressure-Relieving Ankle Foot Orthosis . . . Diagnosis, Spinal Cord Injury 344.1" - to me, THAT explains why it was denied. Spinal Cord Injury as a diagnosis, in my humble opinion, does not necessarily "cause" heel pressure sores, so it makes sense that it was denied -ugh!

    So - Danny goes to wound care on Tuesday morning. I was hoping to have specific information/verbiage to give to the doctor there so HE can write a prescription with the CORRECT diagnosis which would indicate pressure-relieving orthotics, maybe say, heel pressure sores? (I don't know the code . . .)

    There are two products listed on the paperwork from the doctor. One is a Pel Supply Prafo Adult Ankle Foot Orthosis (SKU PE650SKT - price is $223.11 each), and the other is a Prafo 650 Custom AFO ($120 each) - what a difference!

    Any suggestions on anything I/we might be able to compose to at least attempt appealing this decision. Thanks!

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