View Full Version : PacifiCare Denied TLSO Brace

01-02-2008, 05:25 PM
Does anyone out there have PacifiCare (or United Health) and did you have a hard time getting them to pay for your child's TLSO brace? They have denied Mackenzie's brace saying that orthotics are not a covered service. I have explained that it is a back brace for scoliosis (and it was coded by the brace company as CPT L1200 which is the correct code for a TLSO brace). But Pacificare keeps saying that orthotics are not a covered service. I have reviewed the Summary of Benefits and it never mentions orthotics in either the covered or excluded services.

If you have had this situation, I'd love to hear how you resolved it. We have the PPO product (not the HMO). I am so frustrated with them. I have talked to them 3 times and each time they tell me they will resubmit the claim - only to have it denied again. The bill is nearly $2400!

Any help would be greatly appreciated!!!


01-03-2008, 11:44 AM

Do you have a benefit entitled "Durable Medical Equipment" or DME? That is what braces fall under. Usually there is a cap per year. Good luck!


01-03-2008, 12:56 PM
I don't have that health care, but the billing service for the doctors office might be more in the know of how to get it covered. I would document how to get it done because my kids insurance has been charged as much as $5000 for that brace. Em

01-03-2008, 01:13 PM
Thanks Desheah and ecnw. I'm waiting for a supervisor to call me back (what do you think the chances of that are??? ha!).

Anyway, I do have DME coverage with a $5000 annual max, so I'll try that approach. Hopefully I won't have to go the "Consumer Dispute" route with the letters and the "proof" etc. What a hassle. How many different ways do these insurance companies have of trying to deny coverage when they KNOW that it's a covered service. I'm sure they're hoping I'm ignorant and won't fight back. Makes you wonder how many people do just cave in and pay out of their pockets??

I'll keep you posted. Thanks again.

01-03-2008, 05:39 PM
i think that they basically try and wear people down. i have gone through the dispute route many times. while you wait for your insurance company to call you back, it wouldn't hurt to get in touch with your ortho's office and have them send you a letter stating why your child needs the brace. at least this way you are moving forward if you do need to dispute anything.

by the way, any insurance person who doesn't know that orthotics (any of them) fall under durable medical equipment is NOT TRAINED! geez, where do they get these people????

good luck!

01-03-2008, 07:17 PM
My son's endocrinologist got his insulin pump covered. She wrote a letter to the doctor in charge of reviews? I don't remember exactly what she addressed it too. She stated all the reasons he needed an insulin pump. Stated that it was the STANDARD of treatment rather than the exception. Asked to correspond verbally or in writing with them. The pump was covered eventually. Good luck!

01-04-2008, 12:20 PM
Thanks Cheryl and Desheah. The Pacificare Supervisor called this morning and I missed her. She promised to call back within the hour. Hopefully she will.


The Slice
01-07-2008, 02:58 AM
Macksmom, if your health insurance is through your employer, perhaps you can talk to someone there that can help clarify what is and isn't covered under your insurance. HR is the probably the best place to go. Also, see if there are other co-workers (yours or your husband's) who have other issues similar to this, or have any info that may help you on this. This info may help you build a case in your favor with the insurance company. Just a thought, that when I read "orthotics", I immediately thought of the specialized inserts that are put in shoes. I don't have any idea of whether it would make any difference, but is it possible that they are confused about what you are asking for coverage on? I hope all works out for you. Remember that if by chance, the insurance company will not cover it bottom line, that there's a good chance that the brace company will allow you to pay for the brace in installments. Be sure everything is well documented including receipts for payments already made (if any), this way you can be re-imbursed if it turns out that it is covered.

01-07-2008, 12:51 PM
Thanks for the info. I talked to the PacifiCare Supervisor and of course, she says it's all just a misunderstanding. That they'll cover the brace as DME as soon as they get a letter of Medical Necessity from the ordering physician. This is the first I'd heard that. I'm guessing they just hoped I'd go away.

Anyway, I called and left a message with Dr. Bhatia's office to call the Pacificare Supervisor so they could fax the letter to them. Hopefully they'll do it. Of course, I asked his office to call me back to confirm - but I'll stay on them until the letter is sent (especially since I switched my daughter to Dr. Skaggs in August - we may not be a priority).


01-07-2008, 12:55 PM
at least things are moving forward now, but it always does seem to involve multiple phone calls to everyone! i'm sure all of us on this board can empathize!


The Slice
01-07-2008, 06:00 PM
Macksmom, that's great news! It sounded too bad to be true. I had a pretty good feeling that it was a matter of a misunderstanding or miscommunication.

01-15-2008, 01:15 PM
I asked our insurace (Kaiser) no less than five times about covering the brace cost when I heard my child might need a brace. They promised they'd cover it. This is what was faxed to me:

Orthotic Devices
We cover rigid and semi-rigid external Orthotic Devices that are used for the purpose of supporting a weak or deformed body member, or for restricting or eliminating motion in a diseased or injured part of the body. Examples of covered Orthotics Devices include, but are not limited to, leg, arm, back and neck braces.

See if your insurance company will accept the brace with this language. I assume you had a doctor's prescription for the brace.