Insurance appeal for cardiac rehab
Insurance appeal for cardiac rehab
Hi rehabbers -
BC/BS denied my insurance claims for cardiac rehab after I had valve surgery. When I complained, they told me I could make a written appeal. I wasn't really sure what I had to convince them of, so I just tried to justify rehab as medically appropriate. They ended up paying the full amount. I still don't know what reversed their decision; was it my eloquent appeal, or did they just decide I was too big a PITA? At any rate, the following is an excerpt from my own appeal -- plse feel free to borrow any of the language if you think it may be useful to you.
-Bill
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Rationale for Appeal:
Here are my thoughts on why I believe my treatment is in fact a covered benefit:
1) Phase II cardiac care is standard protocol for patients following open-heart surgery. This is not a recreational exercise program; it is carefully controlled and monitored clinical evaluation of my heart function to rule out exercise-related complications. A key objective of monitored sessions was to demonstrate that I had achieved a stable level of exercise tolerance without ischemia or arrhythmia.
The American Heart Association recognizes heart valve surgery as an indication for cardiac rehabilitation:
Indications for Referral to Cardiac Rehabilitation
· Coronary artery disease (particularlywith modifiable coronary risk factors or poor exercise tolerance [ 6 METs or inadequate to meet domestic or occupational needs])
· Myocardial infarction
· Coronary artery bypass surgery
· Cardiac transplantation
· Heart failure
· Percutaneous transluminal coronary angioplasty
· Valvular surgery
From: "Cardiac Rehabilitation Programs, A Statement for Healthcare Professionals From the American Heart Association"
2) Prior to my surgery, I had several tests and physical examinations to assure that I was healthy enough to undergo surgery without undue risk. These included chest x-ray, echocardiogram, blood tests, physical examination by a cardiologist, and an ECG. All of these were covered, as one might presume. Using that same logic, it seems to me that similar precautions (careful monitoring of supervised exercise) would be covered to assure that I could safely resume a normal and active lifestyle without undue risk of arrhythmia or cardiovascular accident. Such risks are well-documented in medical literature, per the following excerpt:
COMPLICATIONS SPECIFIC TO ORGAN SYSTEMS
Heart and Pericardium
Postoperative complications involving the heart and pericardium are common after cardiac surgery primarily because of arrhythmias, conduction disturbances, and manifestations of ischemia.
From "Cardiac Surgery in the Adult," L. Henry Edmunds, Jr.
I would like to point out that my cardiovascular function was significantly diminished following surgery. My ejection fraction was 35% (see the attached echocardiogram report), I had rapid resting heart rate of 110 BPM, and resting blood pressure of 90/40.
3) My rehabilitation services were limited to what was medically necessary. I opted out sessions that provided lifestyle counseling, limiting services to monitored exercise. Although 24 sessions were prescribed by my cardiologist, I terminated treatment after 12 sessions when I demonstrated achievement of moderate exercise levels without adverse effects.
I ask that you please review my case and reconsider payment of claims made by xxxxxxxxx Hospital. If, after your review you conclude that benefits are not covered, I ask that you please provide an explanation of your rationale in writing to me.
