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Insurance, when they deny coverage

  • By Sunnynshare

    Hi everyone,

    I have had a 40 year battle with migraines and chronic daily headaches. I was hoping to get the Omega Procedure through Migraine Treatment Center of America, based out of Dallas, Texas. I have tried every treatment out there that I know of, which is one of the requirements of this procedure. However, I was denied coverage from my insurance company because the procedure was considered an “experimental”. First, if something is approved by the FDA, how can a procedure, especially a treatment of neurostimulation, which the lower spinal stimulators have been around for years, be considered experimental?

    Does anyone know how insurance companies work and how they determine what is covered? Has anyone been able to overturn a decision made by their insurance companies and was able to get treatment? If so, how did you win the battle?

    I really hope someone has had success with this frustration and can give suggestions or insights on this topic. I finally felt like I had a new hope that has now been snatched away and I am bummed!

    Thank you so much!

    Sunnynshare

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  • By Katie M. Golden Moderator

    Sunnynshare,
    I’ve had 2 inpatient hospital stays denied by my insurance company that were eventually overturned and I was admitted. The first one took months. Luckily my doctor’s office had someone who dealt with this all the time and she was great at helping me through the process. Also, many insurance companies have a department that is designated to help you with the paperwork involved in the appeal process.

    One of our writers, Diana Lee, has written multiple articles on this topic and I hope reading these may help you. If going through the appeal process is daunting or you don’t have anyone to help, you can also look into a patient advocate who will take this on for you.

    https://migraine.com/blog/youve-been-denied-what-can-you-do-now/

    https://migraine.com/blog/preparing-a-written-appeal-letter-for-insurance-company/

    https://migraine.com/blog/navigating-insurance-coverage-appeals-under-the-patient-protection-act/

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  • By Sunnynshare

    Hi Katie,

    You have given me a starting point to know how to file the appeal process. I am gathering the information I need and have an appointment with my neurologist and pain clinic doctor in the next couple of weeks. I will go in prepared to both doctors with my information and request them to write a letter in my behalf. I’ve followed the links that you sent me and, hopefully, I can at least get the insurance company to reconsider their decision.

    I think, other than this procedure is still considered experimental, is that I lost my job and am paying COBRA insurance. I understand that the human resources at the company I worked for could also be an advocate for me but they probably would like that I find a different insurance company. The reason we decided to not go for the Obama care is that we had met our deductible through my job and it made more sense to stick with what we have. The new deductible doesn’t start until April 1 so I’m not really sure it would be at our benefit to look for a new policy. It all seems overwhelming to me but you have given me some good suggestions to at least try the appeal process before I look for different insurance plan. I have this small window before we have to decide on an Obama care insurance option.

    I’ll let you know what happens but it may take some time. Thank you so much for your assistance. You have given me some hope.

    Thankfully,

    Sunnynshare

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  • By Katie M. Golden Moderator

    Sunnyshare,
    All of it can be overwhelming. Before you make a decision on Obama Care, you should talk to someone in person at the health exchange. There may be plans that are cheaper than what you are paying now on Cobra with smaller deductibles.

    I personally screwed up when I applied for Obama Care after leaving my job earlier this year. I wasn’t so good with the fine print. So now with open enrollment, I have an appointment set up to talk me through it to make sure everything I need is covered. And you might be eligible for subsidies if you don’t have income right now.

    I hope it all works out for you!
    -Katie

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