I just received a letter from my insurance company. They are denying me an INR testing machine. The docs for the insurance company have reviewed my request and denied it because I don't fall into the high risk catagory. Their quote is below.
"Coverage is provided for a service or supply which is medically necessary. Medically necessary means health care services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (a) in accordance with generally accepted standards of medical practice (generally accepted standards of medical practice are those standards based on credible scientific evidence published in peer reviewed medical literature generally recognized by the relevant medical community); (b) clinically appropriate, in terms of type, frequency, extent, site, duration, and considered effective for the patient's illness, injury, or disease; and (c) not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the patient's illness, injury or disease."
"A Clinical Claim Review Medical Director, has reviewed your request, including all supporting documentation submitted to date. After this review, we have determined that the proposed INRation Monitoring System is not eligible payment. Aetna considers home INR testing medically necessary durable medical equipment for selected high-risk members who, because of severity of illness, instability of control, inability to travel, inability to access home services or other unusual complicating factors, are judged to be candidates for this approach to care. Based on the documentation submitted, the patient does not meet any of the above criteria."
Has anyone else had their initial request denied and then later approved after appeal? If an appeal doesn't do any good I am thinking of waiting until next year to try again. We will have a different insurance next year. The insurance we have right now is such a pain to work with but then again aren't they all. My girls pediatrician won't even work with them anymore. Actually there isn't a pediatrician in the immediate area that works with them anymore.
Hopefully sometime in the near future I will be able to get an INR monitoring system. I'll just keep trying.
Take Care!
Gail
"Coverage is provided for a service or supply which is medically necessary. Medically necessary means health care services that a Physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing evaluating, diagnosing or treating an illness, injury, disease or its symptoms, and that are (a) in accordance with generally accepted standards of medical practice (generally accepted standards of medical practice are those standards based on credible scientific evidence published in peer reviewed medical literature generally recognized by the relevant medical community); (b) clinically appropriate, in terms of type, frequency, extent, site, duration, and considered effective for the patient's illness, injury, or disease; and (c) not primarily for the convenience of the patient, physician, or other health care provider, and not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the patient's illness, injury or disease."
"A Clinical Claim Review Medical Director, has reviewed your request, including all supporting documentation submitted to date. After this review, we have determined that the proposed INRation Monitoring System is not eligible payment. Aetna considers home INR testing medically necessary durable medical equipment for selected high-risk members who, because of severity of illness, instability of control, inability to travel, inability to access home services or other unusual complicating factors, are judged to be candidates for this approach to care. Based on the documentation submitted, the patient does not meet any of the above criteria."
Has anyone else had their initial request denied and then later approved after appeal? If an appeal doesn't do any good I am thinking of waiting until next year to try again. We will have a different insurance next year. The insurance we have right now is such a pain to work with but then again aren't they all. My girls pediatrician won't even work with them anymore. Actually there isn't a pediatrician in the immediate area that works with them anymore.
Hopefully sometime in the near future I will be able to get an INR monitoring system. I'll just keep trying.
Take Care!
Gail
