I just spent a month in a nursing home, thanks to cellulitis that prevented me from wearing my prosthetic leg (I’m going home tomorrow, thank Og!). My insurance (Highmark Blue Shield) has had no real problem approving my continued care here, including physical therapy. Room and board here alone are $10,000 month. I’m sure PT is on top of that.
And yet they just declined to pay for a walker sling, which is at worst $150 and is a durable medical device (which means that I can use it until it falls apart, which is quite a while judging from how much punishment the one that belongs to the therapy department has taken in two separate stays (yes, it’s the same sling I was using when I was here two years ago).
At what point do insurance companies balk? Especially when it makes little sense, as this one does? “We’ll pay insane amounts for an ephemeral service that is used up in practically the same second that it’s administered, but we won’t pay what’s pocket change for us for a device that’s going to last you years.” Where’s the cutoff and what’s the rationale?
I work for a health insurance company, but I can’t give an answer without more information. What was the stated reason they gave for denying it- was it not medically necessary or not a covered benefit or not an in-network provider? At my own company, if it’s a par provider and a covered benefit we don’t question the medical necessity unless it gets into at least several hundred dollars.
Ha! You know, I just realized I never asked the therapy director. I’ll try to get that information today. The truth is that I can probably manage without it around the house, but I would likely need it to go back to work as early as I want to, before I can wear the prosthetic all day.
I went through some similar stuff last year. It turns out that most medical equipment is not covered by my (pretty good) insurance. I was told that they didn’t cover any medical equipment in any circumstances when I called them, but they did cover a hospital bed rental when asked. So maybe just not purchases? For six months of bed and bedrail rental, I tend to wonder if simply buying one would have been cheaper!
They will balk, eventually, about nursing home care, in my experience (I was in, too, for rehab/PT). It depends on the situation. For me, it took about 6 weeks. Once I heard they were making noise about getting me out and demanding additional documentation, I was kicked out within 48 hours – and on a weekend, no less.
It turns out that I got orders to be allowed to wear my leg for four hours at a time with an hour off between, so I don’t need the knee sling, after all. And I should be able to extend my FMLA, just in case.
But before I saw this post, my WAG was that they have limits on how often you can get a brand-new sling. Durable goods are called that for a reason. (This came to mind because my mother would really like a new wheelchair, but the insurance company won’t pay for it until 2015.)