Blue Shield of California - FEH!

The BBQ Pit
1

Apparently the protocol is such that a bone density scan is not approved until a woman reaches age 65. I’m pretty sure they have better protocol in every other “civilized” nation in the world. So I said to the phone rep, after my appeal was rejected (my family history include mother with early onset osteoporosis resulting in multiple fractures and complete disability), “I guess you guys would rather pay for my hospitilizations related to traumatic fractures”. Some MD is being paid a jillion dollars by Blue Shield to make sure no one gets scanned too early, since I was told it was his decision. My MD is trying his hardest to get me the best care available, and all for naught.

Haven’t we all heard for the last umpteen years that bone loss can begin in your 30s??? WTF are they thinking, a 65 year old woman could have lost a huge % of her density by that age.

I’m going in for total hip replacement (at age 50, geez I wonder if there could be something wrong with my bones :smack: ) and I’d like to know that my entire femur won’t crack and split when they violently break off the head of the bone in surgery.

Give me a friggin break.

2

How much does the scan cost? Is there any way you could pay for it yourself? There are many times I have paid out-of-pocket for health care that was not covered by my insurance (in the U.S.) or by public health coverage (in Australia). For instance, in Australia, pap smears are only covered every two years. I get a pap smear every year and I request the Thin Prep method, which isn’t covered. I have to pay out-of-pocket to make that happen.

Since you’d like the scan to happen before surgery, if you can afford it, I’d go ahead and get it done then fight the reimbursement issues later.

Just for the record, in Australia, Medicare (the national health coverage) does not cover bone density scans unless you have certain already-diagnosed medical conditions and will not cover preventative screening, even after a certain age. I found one website that said the cost of the scan, if you paid for it, would probably be around A$81, which is the Medicare schedule fee.

3

Is there any provision in your insuracne to differentiate between a bone scan as a **screening test ** and one ordered as a diagnostic test?

It sounds as though there are valid medical reasons for you to receive a diagnostic test - just as there would be in any age person with various medical conditions. If that’s the case, one would hope insurance would cover valid medical tests.

If not, perhaps your physician could order another test that looks at bone density. (There are several out there).
Using bone scans as a screening test for osteoporosis in people without symptoms would do more harm than good in populations under the age of 65. So I’d applaud your insurance for having the brains to know that and not cover it.
There’s a long, technical explanation why most across-the-board screening tests in low-risk populations are, to put it most efficiently, stupid. They have a great emotional appeal - but can do more harm than good. The long, colorful history of screening mammograms is another example.

4

beckwall, that sucks!!! Just another evil of the health insurance industry. Thankfully, some states are trying to pass laws to require insurers to cover these tests for people other than ones older than 65. Take a look at some of the bills that were introduced this year (all are still under consideration, none have been approved yet). Also, according to my research, no similar bills have been introduced in California in the past couple of years. You should call your state representative and ask him to introduce a bill similar to these ones…

(Bolding mine.)

http://www.in.gov/legislative/bills/2005/IN/IN0150.1.html
Indiana SB 150 requires certain group health benefit plans to provide bone density testing coverage to women who are at least 45 years of age.

http://www.mass.gov/legis/bills/senate/st00/st00689.htm
Massachusetts SB 689 mandates insurance coverage for bone mass measurement testing for the diagnosis of osteoporosis. It also requires the commissioner of insurance to promulgate rules and regulations setting forth requirements and conditions of coverage for bone densitometry; requirements and conditions of coverage shall include: (a) for women who have falling estrogen levels, and who are not already using estrogen replacement therapy, coverage shall include the expense of two bone density tests in a lifetime provided that no other clinical indications of rapid bone loss arise, in which case coverage shall not be limited, but shall be provided as necessary; and (b) coverage shall be provided as necessary for patients who are diagnosed with a clinical condition, other than a falling estrogen level, which indicates rapid bone loss. In setting such requirements and conditions with respect to conditions other than a falling estrogen level which indicate rapid bone loss, the commissioner of insurance shall review the recommendations of the National Osteoporosis Foundation.

http://www.njleg.state.nj.us/2004/Bills/A2000/1706_I1.htm
New Jersey AB 1706 and SB 481 require health insurers to provide benefits for expenses incurred for bone mass measurement. The Commissioner of Banking and Insurance shall establish standards regarding the frequency with which a person shall be eligible for bone mass measurement benefits.

http://www.njleg.state.nj.us/2004/Bills/S0500/212_I1.htm
New Jersey SB 212 requires health insurers to develop guidelines which establish the insurer’s policy for determining when bone density tests are medically indicated, and to provide benefits for bone density tests that are performed in accordance with the guidelines. The bill provides that, at a minimum, the guidelines shall take into account co-existing medical conditions, family history and lifestyle practices and medications that place a patient at risk for osteoporosis.

http://www.leg.state.or.us/05reg/measures/sb0900.dir/sb0971.intro.html
Oregon SB 971 requires health insurers to provide coverage for bone mass measurements as follows: (a) For the purpose of diagnosis of osteoporosis in symptomatic or at-risk individuals at any time upon referral of the individual’s health care provider; and (b) Annually for women 45 years of age or older for the purpose of early detection of osteoporosis.

http://www.legis.state.wv.us/Bill_Text_HTML/2005_SESSIONS/RS/BILLS/hb2613%20intr.htm
West Virginia HB 2613 requires health insurers to include a benefit for an annual osteoporosis screening for each insured above the age of 30. In addition, the insurer must provide for the treatment of osteoporosis. If the insurer provides a pharmacy benefit, the plan must also cover pharmaceutical treatment for osteoporosis.

5

beckwall, you should contact the CA Department of Insurance and start the process for an independent medical review. Since you’ve already had an appeal denied by your insurer, you can start the process. I bet you would have success since your doctor felt it was necessary and since you have a family history and a related condition (the hip condition). Read all about it here:

http://www.insurance.ca.gov/CSD/Brochure/Health/IndMedical.htm

6

Hey, thanks for the info and sites, very helpful. I am woman, hear me roar!

7

YOU GO GIRL!! Stick it to those fat bastards!!

The insurance companies bargain on people either not knowing about other options to appeal their unfair decisions or being too lazy/not sophisticated enough to do it. Don’t be one of those people. With the family history and the existing hip condition, plus your doctor’s support that it is medically necessary, you are bound to succeed! Please keep me posted.

8

Wow, my doctor ordered a bone density scan for me at age 48 when I first started seeing her and she learned my mother has osteoporosis. Never any argument whatsoever about it.

I guess I’ve been lucky with the insurance coverage I’ve had in recent years – either that or Papa T.'s company is big enough to force the insurance companies into offering better plans than the average. Not that I still don’t have to jump through hoops occasionally, but I haven’t been completely denied coverage on anything yet.

I agree, maybe your doctor can order it (or something else that would do the job) as a diagnostic test. Because if you’re having a hip replacement, it sounds like it would be fairly important for all concerned, not just you, to know you’re not going to have problems.