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msrsfeb
LIF Adult
Member since 2/06 1277 total posts
Name:
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Ins: forumla denial question
My ds is on Neosure and when i had my insurance they covered it. Now we are on DH's and his will not cover it. They claim in order for it to be covered it has to be for specific metabolic disorders. My DS was born a day shy of 25weeks and has to be on this formula. Wouldn't this qualify as a metabolic disorder if he must be on this to gain weight etc.? Has anyone gone through this and won their appeal? I am so annonyed!
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Posted 11/24/07 11:51 AM  |
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Long Island Weddings
Long Island's Largest Bridal Resource |
2BEANS
wow time is going fast.
Member since 9/07 16106 total posts
Name:
Tina
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Re: Ins: forumla denial question
i didnt have this situation, but my sis had to fight with ins. to cover her sons formula, not for same reason. I would call your peds and make sure they right a good letter saying that it is necessary baby be on this formula. Also KEEP bugging them, my sis got a denial at first and kept bugging and it adventually got covered and reimburssed the money they had on past formula.
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| Posted 11/24/07 11:55 AM |
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ChrisDee
My Girls
Member since 11/06 9543 total posts
Name:
Christine
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Re: Ins: forumla denial question
I believe if you get a letter of Medical Necessity from your Dr., they have to cover it.
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| Posted 11/24/07 12:01 PM |
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msrsfeb
LIF Adult
Member since 2/06 1277 total posts
Name:
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Re: Ins: forumla denial question
Posted by ChrisDee
I believe if you get a letter of Medical Necessity from your Dr., they have to cover it.
See, that is the thing. They wrote it already. The first one wasn't written well, too baisc. The next one I didn't see it but was supposed to be detailed with the situation. I am going to keep buggging them. I hate ins.! Maybe I should have the hospital send a letter.
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| Posted 11/24/07 12:15 PM |
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BMonster
:)
Member since 2/06 2959 total posts
Name:
Denise
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Re: Ins: forumla denial question
We went through A LOT with trying to get DS's formula covered. We actually got to the point where we were denied 3 times and had to do an external appeal to the NYS Ins. Dept. We JUST got a call on Tuesday that the insurance company decided to withdraw their denial 
What helped us was going through DS's gastro Dr. (it's important to show that they are going to a gastro Dr) who in turn got us in touch with the NYS Attorney's office. They were wonderful in helping us figure out what to make sure we include in the appeal paperwork. There is a NYS Law that states when the insurance company is required to cover formula. It includes things like failure to thrive, GERD, obstruction, and some other things. If the notes & letters from the Gastro & Ped state what is necessary (in the law) and you have the tests and documentation to prove it, they have to cover it.
The insurance companies want you to give up. DON'T DO IT and get the proper help you need. Oh and also keep in mind that they only allow a certain amt of time for each appeal (mine was 45 days).
I hope this helps. Good luck!!
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| Posted 11/24/07 5:27 PM |
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MrsG
LIF Adolescent
Member since 8/06 552 total posts
Name:
M
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Re: Ins: forumla denial question
The law is NY State Assembly Bill 1818A that says they have to cover it. Have you tried going throught Apria Healthcare? They will deliver to your door a monthly supply and they deal directly with your insurance company. Their number is 877-536-8372
Here is a link to a post I made awhile ago with some information. FM me if you have any questions - good luck!!
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| Posted 11/24/07 5:44 PM |
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ChrisDee
My Girls
Member since 11/06 9543 total posts
Name:
Christine
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Re: Ins: forumla denial question
Posted by msrsfeb
Posted by ChrisDee
I believe if you get a letter of Medical Necessity from your Dr., they have to cover it.
See, that is the thing. They wrote it already. The first one wasn't written well, too baisc. The next one I didn't see it but was supposed to be detailed with the situation. I am going to keep buggging them. I hate ins.! Maybe I should have the hospital send a letter.
Sometimes they require a diagnosis code, maybe this will help you.
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| Posted 11/24/07 5:52 PM |
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JavaJunkie
Someday, Somehow
Member since 6/05 5857 total posts
Name:
Lois
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Re: Ins: forumla denial question
We had the same problem when our DS was on Neocate. We had to keep sending appeals and finally get DH's HR dept at work involved. It took about 6 months and then they had to send us a lump sum check of back pay for the formula then they covered it after that. Any money that you spend right now make sure you keep receipts, we had to send them all in!
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| Posted 11/24/07 9:17 PM |
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AOMom
LIF Adolescent
Member since 11/06 856 total posts
Name:
j
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Re: Ins: forumla denial question
Posted by MrsG
The law is NY State Assembly Bill 1818A that says they have to cover it. Have you tried going throught Apria Healthcare? They will deliver to your door a monthly supply and they deal directly with your insurance company. Their number is 877-536-8372
Here is a link to a post I made awhile ago with some information. FM me if you have any questions - good luck!!
DD is on Neocate, not Neosure, but we have it mostly covered by insurance (we have to pay 80%). Mrs. G posted information about Apria on my thread a few weeks back and I contacted them....less than a week later it was covered and I received my first shipment. I HIGHLY recommend contacting them...dealing with your insurance will only give you a headache.
Thanks MrsG!!
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| Posted 11/24/07 9:21 PM |
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