"Experimental" Treatment

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Tirzah
Veteran Member


Date Joined Jul 2008
Total Posts : 2284
   Posted 8/1/2008 9:19 PM (GMT -7)   
Does anyone know how to find out whether a treatment has been FDA approved?

I used to get these nerve blocks all the time & my insurance (same company) always approved it. Now all the sudden at my last visit they tell me that one of them was considered to be "experimental" -- It was a Greater Occipital Nerve Block. The meds in the injection were covered, but the injection itself was denied. I tried calling the FDA hot line, it was just a recording.

I've been getting this nerve block for 10 years now & don't think it's too likely that it's suddenly been reclassified as experimental. My HR rep told me if I can show that it's been FDA approved then she can get my insurance to cover it.

Any ideas?

PAlady
Veteran Member


Date Joined Nov 2007
Total Posts : 6795
   Posted 8/1/2008 9:28 PM (GMT -7)   
Frances,
I would talk with the doctor's office and ask them if it's FDA approved or if something changed. And if it is, how you can find some proof. They should be able to help you if the doc's doing the procedure. He/she should certainly know it if it's considered experimental for some reason.

Also - make sure an accurate procedure code was used when it was billed and authorized. There are constant changes in procedure codes, and insurances can also change what category they put a procedure into. But a lot of times I've found the wrong code was used, and that created the problem. Your doc's office should have had the procedure preauthorized - unless it wasn't required.

PaLady

tom inpain
Regular Member


Date Joined Jul 2008
Total Posts : 239
   Posted 8/1/2008 9:31 PM (GMT -7)   
Hey Francis: i am scheduled for the same block next week- darn we have a lot in common however I have not been denied so far. Never know. Should I be denied I'll reply by using the denial as a topic so You know that i got denied to. This block was ordered by my neurosurgeon. I believe if I am denied it is the Doctors job to appeal and argue on my behalf. tom
Tom Lasko


Tirzah
Veteran Member


Date Joined Jul 2008
Total Posts : 2284
   Posted 8/1/2008 10:03 PM (GMT -7)   
Thanks, Tom.
I did check on the procedure code with my insurance company. I looked up the code & it was correct.

My doc's office wasn't terribly helpful. They just said they couldn't do any more & needed payment from me. I took care of it, but still it was a hundred some dollars that I really don't have. I know they get as aggravated and I do with all these stupid, ever-devolving rules that the insurance companies make up based on research which was probably done by some guy out of his van down by the river http://www.healingwell.com/community/emoticons/tongue.gif so I try not to press them too hard when it comes to insurance rules.

Normally my doc's pretty cool about these things & if he knows it's gonna be denied he comps it, so I was kinda surprised when I found out it wasn't covered. My insurer randomly changes the number of facet injections allowed at an office visit, regardless of the medical necessity. My doctor thinks that's bad practice, so he keeps giving me the same number of shots & only bills me for the number I'm "allowed" to get covered at the time. Usually that amounts to a few hundred up to a few thousand dollars per visit. Because of that, I don't want to "rock the boat" with him too much, but if I can get this covered on my own all the better.

Let me know if you have any better luck getting yours paid for. Sometimes I've been able to "trick" the evil insurance gremlins http://www.healingwell.com/community/emoticons/devil.gif into covering something by referencing other companies who cover it.

hee. hee. hee. (jk, I don't really have an evil laugh like that) :)

PAlady
Veteran Member


Date Joined Nov 2007
Total Posts : 6795
   Posted 8/1/2008 10:57 PM (GMT -7)   
Frances,
I'm surprised your doc's office doesn't tell you up front if a procedure isn't going to be covered. They're really supposed to, at least as a provider for a particular insurance company the policy generally is that the doc/ provider calls for pre-authorization. I always double check when I'm having an expensive procedure that it was authorized, because I can't afford to get hit with the bill.

If other insurances are covering it that actually is a good way to challenge them, because it usually means it's FDA approved or close. I'm not sure if checking the FDA website would help, as well as maybe a general search on the web, or on medscape/medline.

Maybe I could send the Pirate to scare the insurance company into paying? LOL

PaLady

PAlady
Veteran Member


Date Joined Nov 2007
Total Posts : 6795
   Posted 8/2/2008 10:27 AM (GMT -7)   
Frances,
Tspauld actually put more clarity on what I was trying to say earlier. You actually may have more than one code for the same procedure, and sometimes it gets messed up between doc's office and insurance. Or the insurance changes and they're only covering one of the procedure codes when they used to cover two or three. This happens all the time. And docs office may not catch it.

Also remember procedure codes are different from billing codes - as if one wasn't enough! Sometimes I've been able to figure this out and get the codes myself, but only after a lot of time spent on the phone with doc and insurance company. Usually, though, the doc's office has to supply the procedure code. And if something changed recently with insurance it may not be in doc's office computers yet.

Then again, it just might be something with the FDA. The fun never ends!

Good luck!

PaLady
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