Aenta PPO and no orthotics coverage

[livingtwisted]

I'm wondering if anyone has had this same experience... I have been checking on the coverage for particular braces through my insurance and they were mainly quoting me Out Of Network rates, which wasn't great, but manageable. And then one time that I called they checked my plan and said that unless it specifically states under Durable Medical Equipment that Orthotics are included then they are not covered AT ALL, and the previous quotes had been incorrect. And because it's just plain not a part of my plan, there is no way to request that they review it or make an appeal. It's really frustrating, but I'm glad I called enough times to get this info before I go through with it rather than after.

But it seems really strange to me that it's something my employer would have to opt into. I'm considering asking my employer about it, but I don't really want to make a big fuss or have them worried about my health. Is it possible they just overlooked it? Even if that's the case, I can't imagine that they could add it mid year. I'd love to hear from anyone who has had a similar experience or is just a pro at dealing with the insurance co's.

[leahdragonfly]

Hi Mehera,

My personal experience with insurance companies is that a lot of the people answering the calls have very little clue about what orthotics are and how they are covered. Once I called to inquire about a scoliosis back brace for my daughter, and after several minutes on hold while they checked my coverage, the representative returned and told me any type of leg brace would be covered. I had a hard time getting her to understand it was a back brace!! How sad is that. Sometimes, also, they don't understand your request because they use different terminology (insurance-speak). Try explaining what you want in a different way.

I am curious though, are you interested in an orthosis for yourself? It seems like if you are looking for one for pain (which is I think the only indication for an adult with scoliosis to wear a brace) it should be covered.

You might try calling back again and ask if you can speak to the department or person that handles durable medical equipment. I finally had to do that to get correct answers for my daughter's brace. You will probably have to be polite yet quite firm.

Finally, if you have a prescription from your doctor for a brace you can have the doctor's office submit it for an estimate of coverage. Many times these insurance companies really can't tell you anything until they have paper in front of them with codes on it.

Good luck, be persistent,

[JessicaNoVa]

We have Aetna PPO for our insurance and my plan benefit summary just states "Durable Medical Equipment" in plan 20% out of plan 40% (both after deductible). It doesn't specifically mention orthotics.

My daughter's brace was covered, but since we went with a maker that was out of plan (in order to get an RSC brace) we paid 40% of the cost.

I found this information on Aenta's site: Scoliosis Policy

[livingtwisted]

Jessica,

Thank you for the link! How did you find that? I find their website so frustrating. Unfortunately based on my last call it sounds like I may fall into this category:

Note: Some plans exclude coverage of durable medical equipment (DME). Please check benefit plan descriptions for details.

Did you remember if your plan specifically mentioned orthotics under DME?

Gayle,

Thank you, I have called several times, been passed around to different departments and supervisors, but I think I will call and try to word it differently to be sure. On one of the calls the woman did keep talking about feet. On another call they told me the only way it would be covered is if I was diabetic. Because it is a PPO they aren't interested in seeing a prescription, but I have called and given them the specific codes and providers and when I do they give me the Out Of Network rate which for me is a $2000 deductible, then 60% of reasonable & customary is covered. They even gave me what is considered reasonable and customary for that code in the provider's zip code. But the last time I called they said those quotes didn't matter because orthotics are not specified on my plan.

To answer your question, the brace would be used in conjunction with Schroth exercises. The way I understand it, there will be space inside the brace for me to exercise and expand in all the right places with the guidance of the brace to tell me what is correct. I would only wear it while exercising and at night to sleep. I have already been trying to self correct my sleep position which is helping, so I suppose this would just take it to another level. All of this is for pain relief and to prevent any future progression/pain. The schroth is more important to me than the brace, but I want to get everything possible out of schroth and this is what has been recommended for me.

[livingtwisted]

Update

Well I called back again today and got a new answer. I was told as long as it was deemed medically necessary then it would be covered. They referred me to the same link Jessica had posted as to what the criteria would be. I was a bit insistent that they confirm the last answer I was given was not correct since it seems to keep changing. So they suggested I have the orthotist submit for predetermination. Again something that had come up in previous calls, but I was told that this treatment wasn't eligible for predetermination. But I guess it doesn't hurt to try. I have an appointment tomorrow and will ask if they are able to submit it. If anyone has any other advice I'd appreciate it.

[mamandcrm]

Hi Mehera, I think you need to get your doctor not your orthotist to submit for predetermination or precertification. He/she is the one who can show medical necessity by paperwork, via back and forth with the insurer. For example, a doctor may order a CT scan (for whatever condition or injury). An insurer may want a showing of medical necessity before allowing coverage. It is not the CT scan provider who engages in that process, it is the prescribing doctor. Same thing for an orthotics prescription I would think. Your doctor should be willing to do this for you.

[livingtwisted]

Hi mamandcrm,

Do you think it would be my GP or orthopedist? I actually asked that question and was told that the orthotist could do it because they would have the correct billing codes to submit. Maybe it has something to do with it being a PPO because referrals aren't required? I've talked to so many different customer service reps now and they all say different things. It's so hard to know which ones actually know what they're talking about! Since I'm seeing the orthotist tomorrow I may as well ask, but if he says my doc needs to do it, that's where I'll go next.

[JessicaNoVa]

Jessica,

Thank you for the link! How did you find that? I find their website so frustrating. Unfortunately based on my last call it sounds like I may fall into this category:

Did you remember if your plan specifically mentioned orthotics under DME?

I only have my plan summary, which has no clauses listed under DME. I found that link when we first found out my daughter needed a brace and I used good old Google to see if I could find out what Aetna would cover. We then called Aetna and got a pretty straight forward answer as to what would be covered. I'm sorry you're getting the run around! Been there, done that. No fun.

Our orthotist asked us to bring a "letter of medical necessity" which my daughter's orthopedic surgeon's department provided with no problem.

[mamandcrm]

Hi Mehera, whoever is prescribing the brace, which presumably is your orthopedist. I think the codes just tell the insurance company specifically what procedure or treatment is being requested but not why it is necessary. A simple form letter of medical necessity might be enough. It seems to be for kids who are using braces for treatment of the deformity, but use of brace for pain may be a different matter. The insurance company may want supporting documentation (e.g., the doctor's dictated notes about your condition) from your orthopedist. Doctors' offices do this all the time so it shouldn't be a big deal to them to deal with the insurer on this if that's what is needed. I recently dealt with a precertification (not scoli-related, but orthopedic), which strictly speaking wasn't absolutely necessary, but was desireable as I got a letter in the mail up front stating what would be covered and what wouldn't. It took about a week. My doctor's office did the whole thing. I do have a PPO. And, yes, you probably will get some different variation of an answer everytime you call.

[livingtwisted]

Well, I don't know why I was given so many different answers, but when I was at the orthotist today they called my insurance and said that it would be covered In Network (phew!). All they need is a letter prescribing the brace from either of my docs. I'm obviously not asking the question right or something and maybe from now on I'll leave it to the pros. But I was worried about getting in over my head without knowing what my coverage would be so thanks for helping me think through this. I think it's complicated by the fact that as an adult we are really left to do the research and make decisions about non-surgical treatment our own, even more than usual. Both my GP and Ortho are aware of what I'm doing and support it, but they didn't specifically prescribe anything. That was up to me.